Watching Women's Health

Vaccinating males for HPV

It has been almost three years since the FDA approved the HPV vaccine for use in girls and women age 9 to 26. Some of my patients have asked why we don't vaccinate males for HPV. Don't men get HPV too? And isn't that who most women get it from?

Good questions. Men do get HPV and pass it to women. But the consequences of HPV infection are different for the two genders.

Females have an area on the cervix, the transformation zone, that is especially vulnerable to effects of HPV. Persistent HPV infection puts women at particular risk for cervical cancer, in addition to cancers of the vagina, vulva and perianal area.

HPV infection causes cancers in men too, but less commonly and with less deadly results. In the US, about a 1,000 men per year die from HPV-related cancers, involving the penis, anal area, mouth and throat.

More than four times as many women die of cervical, vaginal and vulvar cancers. And, treatment of cervical precancers increases the risk of preterm delivery in subsequent pregnancies. So it was reasonable to vaccinate girls and women first.

Recently, Merck & Co, manufacturer of the HPV vaccine, asked the FDA to approve it for use in males too. Today, The Washington Post reports on how the debate about vaccinating males has been different from the debate three years ago about vaccinating females.

Much of the earlier discussion centered on the question of whether the HPV vaccine would encourage girls to become sexually active at an earlier age. Most of the discussion about male vaccination has focused on safety and cost-effectiveness. 

Gregory Zimet, a professor of pediatrics at Indiana University quoted in the article, says "The cost-effectiveness studies are really important, but I don't think they should be the sole driver of public health policy."

Zimet also says, "This is a vaccine that principally benefits women's health. I wonder if it was the reverse, and there was a vaccine for women that helped prevent prostate cancer in men, this would be as much of an issue." He notes part of the case for men to be vaccinated is an "altruistic argument," which makes it more complex. Some of Zimet's research on HPV has been funded by Merck.

A recent article from the American Board of Family Medicine looked at adult male attitudes toward HPV vaccination. Men were most likely to accept the HPV vaccine if they were well-educated, knowledgeable about HPV and had personal behaviors that put them at higher risk for HPV infection.

The factor least likely to make them want to be vaccinated was a request by a partner. Right now, it doesn't seem like altruisim is high on a lot of guys' lists.

My view is that both genders will benefit if we can reduce the burden of HPV-related cancer and precancers. If the HPV vaccine continues to have a good safety record and is shown to have long-lasting effectiveness, it makes sense to vaccinate the boys and men too. After all, they are part of the problem.

Update on the HPV vaccine

I chose ob/gyn as my specialty partly because most women believe in preventive health care. It is very rewarding to work with patients who are willing to look ahead, and who have the foresight to accept inconvenience now for a future benefit.

Increasing acceptance of the vaccine to protect against the human papillomavirus (HPV) shows young women and mother-daughter duos definitely have that foresight. Women are  becoming informed about HPV and are using that knowledge to protect themselves.

In 2006, the FDA approved the HPV vaccine, Gardasil, for use in girls and young women ages 9 to 26. The vaccine protects against subtypes 6 and 11 (which cause almost all genital warts) and 16 and 18 (which cause 70% of cervical cancers).

The remaining 30% of cervical cancers are due to about a dozen other HPV subtypes not covered by the vaccine. It now appears that the current HPV vaccine offers some protection against these other subtypes.

A recent editorial in The Journal of Infectious Diseases discusses two new studies looking at HPV vaccine cross-protection. These studies showed partial protection against nonvaccine subtypes that could reduce the risk of cervical cancer by another 6% in vaccinated women.

Vaccination against HPV offers huge promise in both developed and developing countries. In developing countries, where women have not had access to Pap smears, cervical cancer is the second leading cause of cancer deaths in women.  The World Health Organization reports  80% of cervical cancer cases occur in low-income countries, where cervical cancer is a major cause of years of life lost in young and middle-aged women.

I saw this heartbreak firsthand while doing volunteer medical work in Jalapa, Nicaragua. One more than one occasion, a young woman with preteen children and far-advanced cervical cancer came to our clinic for help. We could offer comfort, but not a cure.

HPV vaccination is probably our best hope of reducing cervical cancer deaths worldwide. There are many challenges, including cost and logistics of delivering a three dose vaccination.

It also appears the prevalence of HPV subtypes varies in different parts of the world. HPV 16, the subtype that causes the most cervical cancers and precancers in the US, is less common in other parts of the world. Our current vaccine may not offer as much protection to women in developing countries.

The first trials of the HPV vaccine began in 2002, so some young women have been followed for more than 6 years. To date, the vaccine has a good safety record.

We don't yet know how long the vaccine protection lasts. Future trials will likely be conducted in women over 26 and in males. Soon, I'll look at issues involved in vaccinating males for HPV.

Gel may be breakthrough in fight against HIV

Medical scientists have made great progress in treating HIV/AIDS, but we are still searching for more ways to prevent infection. So far, there is no effective vaccine for HIV. But a major prevention breakthrough may have occurred in our hometown.

University of Minnesota researchers Ashley Haase and Patrick Schlievert reported a gel made of glycerol monolaurate appears to block vaginal transmission of the simian immunodeficiency virus (SIV) which is similar to HIV.

In females, immunodeficiency viruses penetrate the cervical and vaginal tissues and infect T cells . Regulatory proteins called cytokines are released and attract more T cells, which in turn become infected.

Glycerol monolaurate (GML) is a natural surfactant that has already been proven safe for human use. When compounded in a vaginal gel, GML appears to stabilize cervical and vaginal membranes so that T cells are not attracted and infected.

The gel could be placed prior to intercourse, so women could independently protect themselves.  Because the gel is inexpensive, it holds huge promise for women in developing and developed countries.

Worldwide, HIV newly infects 2.7 million people per year, more than half of them women. Women most commonly contract HIV by having intercourse with an infected male partner. 

The U of M studies on the GML gel are in early stages.  Let's hope the lab has adequate funding. Larger animal studies and trials in humans must be performed before we know if this is truly a breakthrough in the fight against the virus that has taken so many lives.

HIV — What you don't know can hurt you

Last week, the American College of Obstetrics and Gynecology (ACOG) contacted ob/gyn physicians about more actively screening our patients for HIV. Along with the CDC, ACOG recommends routine HIV screening at least once for all women between 19 and 64. 

According to ACOG, there are more than a million people in the US living with HIV and 25% of them don't know it. Some of these HIV-infected people consider themselves to be low risk and do not ask for testing. Others know they have risks but are reluctant to request testing.

That's why ACOG and the CDC recommend doctors do "opt-out" testing — that is, screen women for HIV unless an individual specifically declines to be tested.  The responsibility is on physicians to include this test in routine care rather than on the patients to ask for it.

After a one-time negative result, doctors and their patients should have ongoing, frank discussions about personal risk factors and the need for repeat screening. HIV screening for both partners entering a new relationship is important. Women who have been diagnosed with other sexually transmitted infections such as chlamydia should also be re-tested.

Women represent an increasing percentage of new HIV diagnoses in the US — 27% of cases in 2005, up from 8% in 1985.

HIV/AIDS is a treatable condition but it has to be diagnosed first. Yes, you may be at low risk, but this is not the same as no risk. With early diagnosis, women can improve their own survival, protect their partners and avoid unintended pregnancy.

Routine HIV testing for pregnant women with an opt-out provision has been the norm in most states for a number of years. This has reduced mother-child transmission of the virus.

It makes sense to extend opt-out testing to gyn care. If your doctor includes HIV screening at your next visit, this is no reflection on your habits or choice of partner. It will just mean your doctor is doing her job.    

Next, I'll write about a promising new gel that may protect women from HIV.