I promised I wouldn’t write every column on HPV (human papillomavirus) or anuses, and I won’t, but bear with me (pun intended) for one or two columns in honor of the upcoming inaugural International Anal Neoplasia Society Conference here in San Francisco beginning Friday November 22nd. I will report on highlights of the conference next month. The connection between the two topics is that HPV is associated with most anal cancers and precancer lesions as well as anal warts.
The most common question I am asked by patients no matter their age, gender or sexual proclivities, is: “Can I pass this to my partner(s)?” The most common question I am asked by other providers is: “Who should get the HPV vaccine?”
There are over 100 HPV types. About 30 effect the genitalia, anus and mouth. They cause warts and cancers of all these areas. Sadly, Farah Fawcett Major died of anal cancer, and Michael Douglas is the poster boy for oral HPV-related cancers. It has been understood for decades that HPV is a necessary cause of all cervical cancers. In the cervix, vagina, vulva and anus we have clear recognized pre-cancerous changes and that is what the Pap smear (cytology) screens for. When a test indicates that there may be a lesion, the individual is referred for higher level testing, which could include a colposcopy exam and/or high resolution anoscopy.
But what about exposure to HPV in the first place? If the HPV weren’t there, none of this would be going on, right? Well, therein lies the problem. Everyone gets HPV. There have been virgin and nun studies done that show HPV exposure. Women who have only had sex with women can be HPV positive. Studies have shown that most gay men (or any MSM) are HPV positive, and with multiple types, especially among HIV-positive men. The only persons unaffected by HPV are those who have never had any sexual contact. No hands, no tongues, no penises, no vaginas touching any or all of these parts.
I like to think of HPV as a pyramid. The bottom of that pyramid is exposure to the virus – and it is universal. As you go up the pyramid, there are the low-grade changes and these includes warts. A nuisance, and no one wants them, but benign. The official medical term for these are low grade squamous intraepithelial lesions (LSIL). Then there are the high-grade lesions (HSIL), which are thought of as pre-cancerous. Since it’s a pyramid, most of these won’t become cancers, but we can’t tell which ones will and won’t progress to cancer, therefore our approach has been to treat them all by removing them. We now know that in women, most of the cervical changes will go away by the time a woman is 30. It is the HPV and lesions that persist beyond age 30 that we have to worry about to prevent a cervical cancer from developing. However, we don’t have similar studies for the anal canal, and research on the oral cavity is in its infancy.
So what do I tell my patients? First, that everyone has HPV and that unless they are sleeping with 16-year-old virgins they don’t need to worry about transmitting HPV to their partners. Everyone can give or get HPV from anyone – straight, gay, anywhere in the LGBTQI spectrum. The exposure to HPV is not the problem, because in a healthy sexually active person there will be exposure to HPV. Once exposed, it’s between the individual and their immune system what happens to that HPV.
While you can give someone HPV, you cannot give someone a high-grade lesion or cancer. I also tell my patients that about 50% of HIV-positive individuals will have a high-grade anal lesion. We also find such lesions in about 25% of HIV-negative GBTQI anuses (lesbians, we get a pass here). The cancers are still rare, about 150 per 100,000 (compared to breast cancer that is more like 11,000 per 100,000), but this is still much higher than cervical cancer ever was. Therefore, if you have an anus that receives or received receptive intercourse and especially if you are HIV-positive, please ask your provider about getting screened with a Pap (cytology) smear. If the test result is not normal – then you should be referred for a high resolution anoscopy exam.
There are two HPV vaccines now that over time should change the natural history of what I just explained – meaning less of all these problems in the next generation of LGBTQI folks. Gardasil contains the 4 HPV types that cause most warts (6,11) and cancers (16, 18). It has been approved for both men and women up to age 27. Cervarix protects against the two cancer HPV types (16,18) and is approved only for women up to age 25. The vaccine is most effective before someone is sexually active. There is some evidence that it may be helpful in people who are already sexually active (thus the approval in men and women up to age 27), and many believe it will help the immune system prevent the development or recurrence of lesions even in people who have clearly been exposed to HPV. These studies are underway. My advice: I don’t routinely recommend vaccination in anyone over age 26, although it is probably safe. I just don’t think we know if it will help, and in anyone over the age of 26, the cost will not be covered by insurance.
I hope to have updates on this and will have more to report next month concerning both the IANS conference November 22-24, and the AIDS Malignancy Conference on November 21st at UCSF.
Dr. Naomi Jay is a nurse practitioner in the department of Infectious Disease at UCSF.