Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, and most people appear to be exposed to the virus shortly after their first sexual experience. Similar to other gynecological conditions, HPV infection is detected more frequently, is more persistent and is more difficult to treat in women living with HIV compared to HIV-negative women. Regular monitoring is the best way to ensure that any problems are detected and treated as soon as possible. This article will highlight some of what is known about HPV and HIV.
HPV is very easily transmitted from person to person, and condoms cannot prevent HPV transmissions as warts around the genital area may shed virus to skin that is not protected by a condom. In most cases, HPV-related disease (genital warts or a pre-cancerous condition called dysplasia) may not develop at all or take years or decades to develop. In addition, the risk of recurrence after treatment is low, suggesting in general that HPV treatment is effective. As with most viruses, however, even when an HPV-related condition isn't present (like when warts respond to treatment and go away), a person still has HPV infection. It's possible that warts or other HPV-related conditions can come back and/or it's possible to transmit HPV to others.
People living with HIV and others with compromised immunity are more at risk for HPV-related complications. Women living with HIV tend to have multiple types of HPV (which is associated with a greater risk of HPV-related disease), are less likely to clear HPV-related conditions (like when warts are more difficult to treat and less likely to go away) and are more likely to progress to HPV-related disease (such as warts progressing to dysplasia).
One study looking at HPV infection in both HIV-positive and -negative women suggests that HIV may be activating dormant HPV and thus increase the risk of HPV-related disease. Immune suppression decreases the body's ability to keep HPV in check. This link was recognized well before the HIV epidemic. In the case of HIV, as HIV progresses, the ability of the immune system to control HPV infection is reduced. This can result in higher levels of HPV and the development of HPV-related disease.
CD4 cell count is a marker of immune health, and HIV viral load is an indicator of how active HIV is in the body. Both of these lab tests provide information for people living with HIV to monitor their health. Studies have found links between HPV-related disease, CD4 cell counts and HIV viral load in women living with HIV. As the CD4 cell count declines and/or HIV viral load rises above 10,000 copies, women are at higher risk for having abnormal Pap smear results and developing HPV-related disease.
Having high levels of HIV (greater than 10,000 copies) has also been linked with abnormal Pap smears and the development of HPV-related disease. More specifically, high levels of HIV have been linked to high-grade dysplasia and cervical cancer (see "Human Papillomavirus: The Basics" in this issue for a description of grades of HPV-related disease). Taken together, what this information tells us is that keeping the immune system healthy and HIV under control may be useful in preventing the development of HPV-related disease.
The goal of anti-HIV therapy is to keep the level of HIV as low as possible and increase the CD4 cell count to at least above 200 and preferably much higher. The data on the impact of anti-HIV therapy on the development and persistence of HPV related disease is conflicting. Some studies have found a regression in HPV related disease, while others have found limited or no regression. The limitation of many of these studies is the time frame of the study and the length of time the participants have been on anti-HIV therapy. One study, called the Women's Interagency HIV Study (WIHS), is looking more carefully at the impact of anti-HIV therapy on HPV-related disease and more information is expected in the future.
What we do know is that HIV-positive women may face challenges when they are treated for HPV-related disease. HIV-positive women may respond poorly to the standard treatment for HPV-related disease and as a result may need multiple treatments using different methods.
The Bottom Line
Work with your doctor in developing a strategy to monitor and manage both your HIV and HPV infection. Optimally this will include regular visits -- including laboratory monitoring of your CD4 cell count and HIV levels -- with your doctor to monitor and track your immune health as well as routine GYN screening and care from a gynecologist who knows about HIV. Working with your doctor to develop an individualized strategy that suits your life-style and needs is the key to living longer and healthier with both HPV and HIV.
For more information about HPV and medical screenings, read Project Inform's publication, "Gynecological Conditions in Women With HIV."
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There are more than 100 types of HPV (human papillomavirus), including 40 which can infect the genital tract and are sexually acquired. Genital HPV infections are frequently asymptomatic and resolve without causing disease. However, certain HPV infections can cause cervical cancer, other cancers and genital warts.
HPV types associated with cancer are called oncogenic or 'high risk' types; 13 have been recognised by the WHO International Agency for Research on Cancer. HPV types that do not cause cancer are termed 'low risk' types. Two of these 'low risk' types cause genital warts. HPV types are referred to by number (assigned in the order in which they were discovered).
HPV infections are extremely common in the sexually active population and are particularly common in the first few years after onset of sexual activity.
The HPA has developed laboratory, modelling and surveillance techniques and systems to describe and monitor the type-specific epidemiology of HPV infections and related disease, and to estimate the expected impact of HPV immunisation.
Cervical and other cancers
Cervical cancer is the second most common cancer in females worldwide and is the 12th most common cancer in females in the UK. HPV is a necessary, although not sufficient, cause of cervical cancer. Around 70% of cervical cancers are attributed to two types: HPV 16 and 18. At least 10 other HPV types are also associated with a high risk of cervical cancer (e.g. HPV 31, 45). High risk HPV infections are also associated with cancer of the penis, vulva, vagina, anus, mouth and oro-pharynx.
Genital warts
Warts are the most common viral STI diagnosed in the UK, with highest rates of new cases in 20-24 year old men and 16-19 year old women. Warts are found on or around the penis, anus or vagina. Low risk HPV types 6 and 11 cause the majority of genital warts. The number of genital warts diagnosed in the UK population has continuously risen since records began in 1971.
Prevention
Cervical screening can detect pre-cancerous lesions and cervical cancers at early asymptomatic stages, when they can be successfully treated.
Two HPV vaccines have been developed that can protect against HPV type 16 and 18 infection (associated with 70% of cervical cancer); one of these also protects against HPV types 6 and 11 (genital warts). Both vaccines are prophylactic, meaning they should be given prior to HPV infection.
UK HPV immunisation programme
In the UK, a national HPV immunisation programme was introduced for all girls aged 12-13 years (school year 8) in Autumn 2008. The national immunisation programme uses the bivalent HPV vaccine (CervarixTM, GlaxoSmithKline) and will protect girls against infection with HPV 16 and 18 (associated with 70% of cervical cancers). A catch-up campaign for girls aged up to 18 years (women born on or after the 1st September 1990) has also been implemented. The Joint Committee on Vaccination and Immunisation (JCVI) has advised that the programme would be most efficiently delivered through schools. Primary Care Trusts in England are responsible for local delivery of the HPV vaccination programme. The JCVI advised that a catch-up programme for all women aged 18-25 years was unlikely to be cost effective but could benefit some individual women: the Department of Health is considering this further.
HPV Vaccine given in pregnancy
There is no known risk associated with giving HPV vaccines during pregnancy or whilst breast-feeding. However, as a matter of caution, HPV vaccine is not advised in pregnancy. The HPA is following all women who are inadvertently given the HPV vaccine while pregnant to gain information that will help better inform pregnant women, their families and health professionals in the future. This surveillance is part of the UK Vaccination in Pregnancy Surveillance Programme being run by the HPA Immunisation Department.
http://www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1191942...