HPV, Gardasil & Anal Pap Smears in Boys and Men

everybodysgood.com is proud to introduce Theresa Schwartz as one of our fabulous guest bloggers. Theresa Schwartz is a nurse practitioner, HIV Specialist and provider of diagnosis and treatment of anal dysplasia, or precancerous anal conditions.

The Human Papillomavirus (HPV) is a sexually transmitted infection that can be spread from the skin of a person who has HPV to the skin of another person through intimate contact, such as vaginal or anal receptive sex. The exchange of body fluids is not needed for the transmission of HPV. Condoms are not very helpful in preventing transmission from person to person, because the virus exists on the thighs, buttocks and scrotum, in addition to the penis. HPV is responsible for most cancers of the penis, anus, and mouth, and of the cervix in women. HPV also causes genital warts. There is no cure for HPV, although many people with competent immune systems can clear infections received up until their mid-twenties. Strains acquired after that age are less likely to be cleared by the body's immune system.

Gardasil is a vaccine that can be given to prevent HPV infection. It contains the four HPV strains that are responsible for about 90% of the warts and cancers that we see. As with any other vaccine, the HPV vaccine works better if it is given before people are exposed to the virus. Ideally, it should be given to people BEFORE they become sexually active, because HPV is transmitted so easily, usually from a person's first or second sex partner.

Since 2007, Gardasil has been available to prevent genital warts and cancer in women and the Centers for Disease Control and Prevention (CDC) said that it SHOULD be given to girls and women ages 9-26. Most insurance companies agreed to cover it.

In 2009, the FDA said that the vaccine was also effective in preventing genital warts in men, and the CDC said that it COULD be given to boys ages 9-26. The reason that the recommendation was permissive and not recommended to be routinely administered, was because there was insufficient data regarding whether it was cost effective to give it to males (1). As everyone knows, health care costs too much already, and so there is always concern that the health care system should not waste money on interventions that are not expected to deliver enough "bang for the buck."

Because the CDC said that the HPV vaccine COULD be given to boys, most insurance companies refused to pay the $400.00 per male (including administration fees and supplies) for the series, which consists of three shots over six months. Until recently, there was no place in Rochester where boys/men could obtain it. Our local Excellus/Blue Cross still will not pay for men to receive Gardasil, citing the CDC permissive recommendation (2). In the spring of 2010, data was published that demonstrated the effectiveness of the HPV vaccine for the prevention of anal cancer in gay and bisexual men.

 

The CDC vaccine committee is now reconsidering whether the HPV vaccine should be routinely recommended for males for the prevention of warts (3), and the FDA is considering data submitted demonstrating the effectiveness of the vaccine for preventing anal cancer in men and women (4).

Unfortunately, discussion of sexually transmitted infections is subject to a greater amount of sexual politics than other illnesses. The idea of universal vaccination of girls against HPV vaccine generated great controversy, because some people thought that meant that girls would become sexually promiscuous, and this made it unacceptable when people were "only" thinking about heterosexual sex! Prior to the recent study by Jane Kim of Harvard, of the cost-effectiveness of HPV in men who have sex with men (MSM) on November 3, 2010 (5), previous studies on the cost-effectiveness of vaccinating men focused on the decrease of heterosexual transmission to women, who could then get cervical cancer! Heterosexism is alive and well.

Obviously, gay and bisexual men deserve to be protected from HPV just as women do. The current issue will now be how to get MSM vaccinated as early as possible. It is unrealistic to expect that nine year old boys will know and be able to state their sexual orientation. A survey of MSM in Australia (6) found that age 20 is a more likely time that men would seek out the HPV vaccine. Even though this would be after two years of sexual activity with an average of 15 partners, vaccination of MSM in until age 26 is still likely to be helpful in preventing HPV infections.

Could the vaccine be given to all boys from age 9, regardless of future sexual orientation? Yes, and it is considered cost effective to do so, but it has been difficult enough to gain acceptance for vaccination of girls. Will there be concerns from conservatives that giving Gardasil to men will encourage anal sex? It could take some time before most males are vaccinated, but this is a worthy goal.

Now is the time for MSM and all males to ask their primary care providers where they can obtain the vaccine and to ask their insurance companies whether they will cover Gardasil and if not, why not. It is important to realize that even though the vaccine will prevent about 90% of the cancers and warts that we currently see, men and women will still need to be screened for anal cancers. The HPV types (not in the Gardasil vaccine) that cause the remaining 10% of warts and cancers can affect vaccinated people. Vaccinated people will not know for sure whether they have picked up one of those remaining HPV types that less frequently cause problems, so they will still need to be checked regularly. But we expect that we will find fewer pre-cancers, cancers and warts in vaccinated people.

Anal Dysplasia practices in the Rochester area:
Rochester Colon and Rectal Surgeons, 125 Lattimore Road, Rochester, NY. 585.244.5670
Strong Memorial Hospital Dysplasia Clinic, 601 Elmwood Avenue, AC 2, Rochester, NY. 585.275.2159

Click here for more information.

 

1 Palefsky, J. Can HPV vaccination help to prevent anal cancer? Lancet Infectious Diseases, 2010, 70226-7. Published online November 3, 2010.

2 Personal communication, November 12, 2010.

3 Kim, JJ. Targeted human papillomavirus vaccination of men who have sex with men in the USA: A cost-effectivenes modelling analysis. ? Lancet Infectious Diseases, 2010, 70219-X. Published online November 3, 2010.

4 Palefsky, J. Can HPV vaccination help to prevent anal cancer? Lancet Infectious Diseases, 2010, 70226-7. Published online November 3, 2010.

5 Kim, JJ. Targeted human papillomavirus vaccination of men who have sex with men in the USA: A cost-effectivenes modelling analysis. ? Lancet Infectious Diseases, 2010, 70219-X. Published online November 3, 2010.

6 Simatherai, D, Bradshaw, CS et al. What men who have sex with men think about the human papillomavirus vaccine. Sexually Transmitted Infections 2009; 85: 148-149.