Commentary Sexual Health

HPV and Things That Go Bump: Time for Action on Genital Warts

William Smith

While we await the expected and demonstrated good news of few cervical and other cancer deaths among person immunized against HPV, a recent study from Denmark already shows us that vaccination can significantly reduce genital warts.

Last year, my organization, the National Coalition of STD Directors (NCSD) increased our focus on disease caused by human papillomavirus (HPV) infection. And while much deserved attention has been paid to the critical outcome of cervical cancer, we also decided to tackle the more frequent clinical outcome of HPV infection—genital warts. Those unsightly, bumpy, cauliflower-like growths that go by the more clinical term condyloma.

Long considered more an unsightly and anti-erotic nuisance because genital warts are not life threatening, they do play a role in the spread of HPV by increasing the shedding of virus and for anyone who’s ever had them—especially when they are invasive—they are more than just a nuisance. Sexual health is more than the absence of disease, so preventing and treating genital warts should be part of our collective efforts. And from a primary prevention perspective, it syncs up directly with eliminating cervical and anal cancers.

While reducing genital warts and cervical and anal cancers is key from a public health standpoint, we decided to look more closely at genital warts from a business perspective. Namely, as public health entities that offer STD clinical services—many of NCSD’s own members—seek to diversify sources of revenue to keep their doors open, getting reimbursed for treating a common STD seems like a way to bring in additional revenue. Diagnosing genital warts doesn’t require much more than a glance from a provider and speedy, in-office treatment is readily available. In addition, patient-applied products have been approved by the Food and Drug Administration (FDA) making treatment even more accessible.

In our scaled up work, we also discovered that genital warts are such a common reason for a visit to a public heath STD clinic that as clinic resources, staff, and hours of operation have been cut back, some clinics no longer see genital wart patients. I was at first a bit stunned by this disclosure, but the reality became clear when one provider said: “If we see all the wart patients, we don’t have the time to see the gonorrhea and chlamydia patients or their partners.” Point taken. But what if those turned away patients could generate streamlined revenue due to easy diagnosis and treatment? It seems to meet multiple needs: public health outcomes, individual patient outcomes, and adding some new revenue to aid dwindling discretionary monies from government.

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So while we pursue diagnosis and treatment of genital warts in public health clinics, we can also turn to primary prevention. Most genital warts—as high as 90 percent of all cases—are caused by two types of HPV,  6 and 11. These two types are among the four types covered by Gardisil, one of the vaccines widely available and approved by the FDA. A study from the British Medical Journal found 82 percent of genital warts are prevented by Gardisil.

Yet, uptake of HPV vaccines in this country remains appallingly low, particularly in the South. In Mississippi, less than 20 percent of adolescent females received all three doses of an HPV vaccine according to the 2011 National Immunization Survey. In Arkansas, only 15.5 percent of adolescent females received all three doses; and in South Carolina, only 23.3 percent.

While we await the expected and demonstrated good news of few cervical and other cancer deaths among persons immunized against HPV, a recent study from Denmark already shows us that vaccination can significantly reduce genital warts.

The February 2013 issue of the journal Sexually Transmitted Diseases highlights a study from Denmark showing the country’s national HPV vaccination program has had a huge impact on reducing genital warts. Since 2009, Denmark has provided Gardisil to all 12-year-old girls and also to those up to age 15 since 2008 as a “catch-up” vaccination. According to the study’s authors, the vaccination program turned the corner on continued increases in new genital warts cases—for women on an average of 3.1 percent fewer cases each year. Moreover, for those young women vaccinated and coming of age—now 16 to 17 years old—genital warts were “virtually eliminated”.

Finally, NCSD has developed a brochure for providers on talking about genital warts that has a great deal of information that might be useful. You can find it here

Focusing on genital warts is in the best interest of patient and public health, as well as a good way to bring in money in an era of dwindling resources. The Danes are telling us something and we should be listening… and acting.

 

Commentary Science

HPV Vaccines Are Working, So It’s Time to Stop Arguing About Them

Martha Kempner

A new study finds that HPV rates have plummeted in the last six years. Yet HPV vaccination rates continue to lag behind those of other vaccines, in part because of the stigma surrounding sexually transmitted infections.

According to a new study, human papilloma virus (HPV) rates have plummeted in the first six years vaccines against the virus have been available. Unfortunately, HPV vaccination rates lag behind those of other recommended inoculations, in part because of the stigma that stifles conversations around sexually transmitted infections.

Perhaps these new success rates—coupled with additional new research that reminds us of the possibility of non-sexual HPV transmission—will convince more parents to take advantage of this potentially life-saving vaccine.

HPV is actually a group of more than 150 related viruses, 40 of which are known to be sexually transmitted. Most types of the virus are thought of as low-risk, because they are unlikely to cause health problems. Nine types, however, have been identified as high-risk and are thought to be responsible for 99 percent of cervical cancers and a large portion of vulvar, vaginal, penile, anal, and oropharyngeal (a part of the throat) cancers.

Since 2006, there have been three vaccines against HPV developed and released on the market. The most recent, made available last year, was the most wide-ranging; it protects against the nine high-risk types of the virus.

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The vaccine is given as a series of three shots over eight months. The Centers for Disease Control and Prevention (CDC) recommends that boys and girls begin the series at age 11 or 12 in order to be sure that they are fully vaccinated before they become sexually active, but those who do not get the shots at that time can get them at any point before age 26. Experts estimate that widespread vaccination could prevent up to 90 percent of cases of cervical, anal, and genital cancer.

Though the research released last month uses data collected before the latest vaccine was available, the success of the original vaccine supports an optimistic outlook for the future prevention of HPV.

For the new study, which was published in the journal Pediatrics, researchers used data from the CDC’s National Health and Nutrition Examinations Survey (NHANES). They compared cervical and vaginal specimens from individuals ages 14-to-34 collected between 2003 and 2006—before the vaccine was available—with samples collected between 2009 and 2012, after the first vaccine was in use. They also used vaccination records from the latter group.

They found that 11.5 percent of young women ages 14-to-19 in the pre-vaccine group had one of the four types of HPV covered by the original vaccine. This dropped to about 4 percent in the group examined after the vaccine was available. Among those ages 20-to-24, the prevalence rate dropped from 18.5 percent to roughly 12 percent. There was no change among the oldest age group.

Overall, the study concludes, within six years of the vaccine’s introduction, HPV rates were down 64 percent among teen girls and 34 percent among women in their 20s.

Dr. Laurie E. Markowitz, lead author of the study, told the Guardian that results were better than expected.“The fact that we are seeing a larger decrease overall than what we expect given our coverage rates does suggest there may be some herd protection,” which occurs when a large enough portion of the population is vaccinated to slow the spread of the virus, she said. “There also may be effectiveness from less than a complete three dose series,” Markowitz continued.

Researchers anticipate that more people will continue to benefit from the vaccines. Markowitz told the Guardian, “As women who got the vaccine when they were younger age move into these older age groups, we should continue to see a continued decrease,” because they will not transmit the strains to anyone else as they become sexually active.

In addition, vaccination rates have improved since this data was collected. In 2009, only about 44 percent of girls had received one dose of the vaccine and only about 27 percent had received all three. By 2014, two-thirds of teenage girls ages 17 and under had received at least one of the three recommended doses of the HPV vaccine, and about 40 percent had received all three doses.

The CDC recommends that boys get the HPV vaccine as well, but vaccinations rates among boys have always been lower than those among young women—perhaps because when the vaccine was originally introduced, it was only suggested for girls, or perhaps because it is best known for preventing cervical cancer. But vaccination rates for boys have been on the rise as well. In 2014, roughly 42 percent of teenage boys ages 17 and under had received at least one dose of the vaccine: about 8 percentage points higher than the year prior.

Unfortunately, HPV vaccination rates still lag behind those of other recommended vaccines. For comparison, in 2014, about eight in ten teens ages 17 and under had received the quadrivalent meningococcal conjugate vaccines and roughly 87 percent had received the Tdap vaccine, which covers tetanus, diphtheria, and pertussis.

There are a number of reasons that HPV vaccination rates might be lower than others, including the fact that only two states and Washington, D.C. require the vaccine for school-aged children. By contrast, the Tdap vaccine is required in most states; meningitis vaccines are required in about half. Additionally, some parents may not have the resources or time to take their children to get a series of three vaccinations.

Not surprisingly, there still exists a discomfort with the sexually transmitted nature of HPV. Since, the HPV vaccine was introduced, there have been those who argue that vaccination will be seen by teenage recipients as permission to have sex, thereby increasing their risky behavior. This faction also argues that it is not necessary to inoculate young people against HPV because they can easily avoid it by just not having sex.

Numerous studies have found that HPV vaccines do not, in fact, turn young people into sex machines. A study last year from the United Kingdom, for example, found girls who have been vaccinated are less likely to engage in risky sexual behavior than those who have not. An earlier study in the United States found that teen girls who had been vaccinated were more likely to use condoms than their non-vaccinated peers. Other studies have found that young people’s perception of sexual risk and risk behaviors do not change after vaccination.

Perhaps a new article will take the wind out of the sails of the argument that teens should “just say no” to prevent HPV. The paper, cleverly titled “Penises Not Required,” reviewed 51 studies that found evidence of transmission through means other than penile-vaginal or penile-anal intercourse. Some of the studies reviewed found HPV DNA in the genital tract of female “virgins”—though the definitions of “virgin” varied widely among studies, and were based on respondents’ self-reported sexual activity. Other studies found HPV DNA in children who had not been sexually abused. Some studies focused on evidence of HPV DNA on medical equipment, toilet seats, and sex toys, and questioned whether this would be sufficient to transmit the virus. And others suggested the possibility of finger-to-genital transmission either from a partner or even from one’s own hands.

The researchers told Rewire in an email that their results have to be interpreted cautiously, as they do not provide proof of non-penetrative or non-sexual transmission. Nonetheless, the possibility that this virus can be transmitted without sex should help us rid the HPV vaccine debate of moralizing. As the researcher concludes in the article, “The distribution of HPV vaccines has been hindered, in part, by societal discomfort with the role of HPV in human sexuality. A fuller appreciation of the potential for non-sexual HPV transmission could help increase vaccine acceptance.”

The facts are simple. We have a vaccine that prevents cancer, it’s working, and that’s a major public health victory. It’s time to stop arguing about whether vaccinating kids against an STD is a good idea and start protecting everyone.

Roundups Sexual Health

This Year in Sex: It’s Time to Take Action

Martha Kempner

We have the tools to work against sexually transmitted infections, harmful "conversion therapy" for LGBTQ teens, and sexual assault on college campuses. Now, we just have to use them.

This Year in Sex takes a look back at the news and research related to sexual behavior, sexuality education, contraception, sexually transmitted infections, and other topics that captured our attention in 2015.

STIs Are on the Rise in Every Group

This year, it seemed like every week there was a new headline about a rise in sexually transmitted infections or diseases among a specific group, in a certain geographic area, or even among the general population. When states released their 2014 STI data, we learned that Minnesota’s rates hit a record high and that the rate of gonorrhea nearly doubled in Montana between 2013 and 2014. Counties across the country reported rising rates of chlamydia, gonorrhea, and syphilis. California’s Humboldt County, for example, noted a tenfold increase in gonorrhea since 2010, and Clark County, Nevada—home of Las Vegas—reported a 50 percent increase from 2014 in the number of cases of primary and secondary syphilis.

In fact, many of the headlines this year involved syphilis—a curable disease that the United States was once close to eliminating because rates were so low has continued its resurgence. A Department of Defense report, for example, points to a 41 percent increase in the rate of this disease among men in the military. Another disturbing report showed a dramatic rise in the number of babies born with syphilis; congenital syphilis can cause miscarriage, stillbirth, severe illness in the infant, and even early infant death. This reflects both an increase in cases of the disease among women and a lack of prenatal testing that could catch and treat syphilis during pregnancy. This year, there was also an outbreak of ocular syphilis on the West Coast that led to blindness in at least one patient.

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While syphilis is on the rise in both men and women, 90 percent of cases are in men, 83 percent of which are those who have sex with men in cases where the gender of the partner is known.

Young people are also disproportionately impacted by STIs, specifically chlamydia and gonorrhea—54 percent of the cases of gonorrhea and 66 percent of cases of chlamydia reported to the CDC occurred in those younger than 25. Though if detected early and treated, those STIs can be cured, they can also cause future health problems, including infertility.

Perhaps the ultimate headline about STIs this year, however, was the one in which we learned that almost everyone has herpes. A report by the World Health Organization estimated that 3.7 billion people worldwide—or about two out of every three adults across the globe—are infected with herpes simplex virus 1.

All of this news should remind us that sexually transmitted diseases and infections are a public health crisis and we have to up a fight. We need to prevent the spread by educating young people and adults and making condoms readily available. We need to invest in testing that can help people detect STIs before they face many potential health consequences and prevent them from spreading further. And, we need, of course, to provide access to treatment and combat stigma-based fear.

We Know How to Prevent HIV (Now We Just Have to Keep Doing It)

There was a lot of good news this year when it comes to preventing HIV, much of which focused on how well pre-exposure prophylaxis (PrEP) can work. PrEP is a combination of two antiretroviral drugs—tenofovir and emtricitabine—used to treat people who have HIV. When taken daily by people who are HIV-negative, these drugs have been shown to prevent transmission of the virus. In fact, a study by Kaiser Permanente found that since the approval of PrEP in 2012, none of the patients who were using it became infected with HIV. This was actually better than the researchers expected given the findings in clinical trials.

Incorporating PrEP into a multifaceted HIV-prevention program can work, and San Francisco—once a hotbed of the national HIV and AIDS epidemic—proved that, with just 302 new HIV diagnoses in 2014. Getting those HIV-negative residents who are at high risk of contracting the virus onto PrEP is one of the strategies the city uses. In addition, the city provides rapid treatment for the newly diagnosed and continued follow-up appointments to make sure that patients stay on their treatment plan. This can not only help them stay healthy but can prevent the further spread of the virus, as people who adhere to an antiretroviral drug protocol can suppress the virus to the point that they cannot transmit it to others. In San Francisco, 82 percent of residents with HIV are in care and 72 percent are suppressed. This is significantly higher than national statistics, which show that 39 percent of those with HIV are in treatment and only 30 are taking their drug regimen regularly enough to be considered suppressed.

While it will be difficult for many places to adopt a system as expensive as the one in San Francisco, its success shows us that we have the tools we need to prevent HIV. And, in fact, diagnoses of HIV are down in the United States by 19 percent, though the success was not evenly spread: some groups, such as Latino and Black men who have sex with men, are actually seeing increases. It’s time to renew our investment in ending this epidemic for everyone.

Vaccines (Including the HPV Vaccine) Are Not Dangerous, But Skipping Them Is

The year started with a massive outbreak of the measles on the West Coast, so it’s not surprising that there was a lot of conversation about the value of inoculations and what happens when too many people in a certain area are not vaccinated. In the midst of the epidemic and the debate, some schools asked unvaccinated children to stay home, and some states tried to close loopholes that make it easy for parents to opt of required vaccines because of “personal beliefs.”

Unfortunately, many of these personal beliefs are based on false reports and misinformation suggesting that certain vaccines cause autism. A study of anti-vaccine websites found that this misinformation is abundant on the Internet. Of 480 sites dedicated to the anti-vaccine movement, about 65 percent claimed that vaccines are dangerous, about 62 percent claimed vaccines cause autism, and roughly 40 percent claimed vaccines caused “brain injury.” Many of these facts lacked citations, but some were based on misinterpretation of legitimate research.

The scientific truth is that vaccines are safe and have no connection to autism. If there was any doubt, yet another study was released this year confirming it. In fact, the only study that has ever found a connection was proven to be falsified by an unethical researcher who stood to make a profit.

Of course, that didn’t stop the field of Republican presidential hopefuls—which includes two medical doctors—from trying to score political points by suggesting the government may “push” “unnecessary” vaccines.

Though not mentioned by name, they may have been referring to the HPV vaccine, which has always been controversial because of its connection to sex. There seems to be a sense that because HPV is sexually transmitted, vaccinating against it is less important or will give teens permission to have sex. Numerous studies have shown this to be false. One study published this year even found that girls who have gotten the HPV vaccine take fewer sexual risks.

But the fear and misinformation continues, and it turns out doctors might not be helping matters. One study showed doctors may be discouraging the HPV vaccine by not strongly recommending it, not doing so in a timely manner (the CDC advises that vaccinations should start at age 11), and only suggesting it to young people they perceive to be at risk. This could be part of why HPV vaccination rates still lag behind those of other recommended vaccines.

We need to remember that this vaccine prevents cancer. The newest protects against nine strains of the virus and has the potential to prevent 90 percent of cervical, vulvar, vaginal, and anal cancer. And there is reason to believe it will also prevent oral cancer. That’s five cancers prevented by one series of shots.

Of course, like the others, it can only work if our children obtain it. Hopefully, it will not take another outbreak of a preventable disease like measles for us to realize how lucky we are to live in an age in which we know how to stop so many of the diseases that disabled and killed generations before us.

Government Weighs in on ‘Conversion Therapy’

This year saw many positive developments in the struggle for LGBTQ rights, one of which was a willingness of both the White House and many senators to come out against “conversion therapy” for young people. Sometimes called reparative therapy, this is the practice of trying to change a person’s sexual orientation or “cure” their homosexuality. While no legitimate medical organizations sanction such a practice, some young people are subjected to it because their parents or their religion disapprove of same-sex relationships.

Conversion therapy can include anything from Bible study to forced heterosexual dating to aversion therapy, in which patients are shown homosexual erotica and shocked every time they display arousal. Research has found not only that it does not work to change an individual’s sexual orientation, but that it can be harmful and lead to depression, shame, and suicidal thoughts.

In April, the White House released a report condemning the practice for teenagers and asking states to ban it for minors. In an accompanying letter President Obama wrote: “Tonight, somewhere in America, a young person, let’s say a young man, will struggle to fall to sleep, wrestling alone with a secret he’s held as long as he can remember. Soon, perhaps, he will decide it’s time to let that secret out. What happens next depends on him, his family, as well as his friends and his teachers and his community. But it also depends on us—on the kind of society we engender, the kind of future we build.” Two Democratic legislators echoed this sentiment when they offered a resolution asking the Senate to condemn the practice as well, and a report from the Substance Abuse and Mental Health Services Administration attempted to offer parents alternatives that can support LGBTQ young people.

This year Oregon joined those states—including New Jersey, California, and the District of Columbia—that do ban the practice. Furthermore, a challenge to New Jersey’s ban failed when the U.S. Supreme Court turned the case away.

Doing away with harmful practices is a step in the right direction for LGBTQ adolescents, but there is still much more to do in order to protect and educate all of our young people.

We All Continued Talking About Consent

The problem of sexual assault on college campuses was pervasive in the news in 2015. At the end of last year, California became the first state to pass a law mandating affirmative consent on college campuses, also known as “yes means yes.” This year, New York joined it, and other states are considering doing the same.

Affirmative consent has its critics, who say that the standard is unclear and unrealistic in real-life settings. A poll by the Kaiser Family Foundation found that most college students (83 percent) had heard of affirmative consent and many (69 percent) felt it was very or at least somewhat realistic. But when asked whether different scenarios met the standard, students showed a variety of opinions, proving that putting the standard into practice might be tricky.

Still, I believe the conversations about affirmative consent have been useful. They have given us a platform to talk more about the role of alcohol in sexual behavior and sexual assault, and what happens when one is not passed out but clearly very drunk—and therefore incapable of giving consent. We’ve made college students more clearly establish their own boundaries. And educators have been able to both reiterate and go beyond the “no means no” message to talk about what good, consensual sex might look like.

Affirmative consent is not the end-all solution to sexual assault—it won’t, for example, prevent some perpetrators intent on raping. But if we talk about it enough and start before college—California, for example, mandated affirmative consent message in high school—we might have a generation who can think critically about their own behavior and the behavior of others, a generation that is prepared for healthy sexual relationships and knows that, at the bare minimum, a sexual encounter must include consent.