HPV
Human Papilloma Virus - Genital Warts

General Information
The Bad News
The Good News
Symptoms
Diagnosis and Pictures
Complications
Treatment
Prevention
Vaccination
Rutgers and HPV

General Information

The Human Papilloma Virus (HPV) is the cause of both genital and non-genital warts. This is a very common family of viruses.  There are actually more than 100 different strains of HPV.  Of these, approximately 30 exist in the genital area and can cause genital warts (condyloma acuminata).  These 30 strains can be further broken down to "high" and "low" risk strains.

High risk strains may cause changes in a Pap smear which may rarely progress to cancer.  There are approximately 13 high-risk strains of HPV, of which two (16 & 18) are believed to cause about 70% of all cervical cancer.

Low risk strains sometimes cause changes in a Pap smear, but do not progress to cancer. Of the low-risk strains, two (6 &11) are most likely to cause genital warts.

This article discusses the genital strains of HPV.

• Transmission - HPV is spread by close genital contact, and is thus nearly always sexually transmitted.  While there have been rare reports of infection from tanning beds, it is extremely unlikely that this virus would be transmitted through shared clothing, bed sheets, etc.
  
• Incubation Period - The time from infection until you have any signs (e.g. a wart or abnormal Pap smear) is both long and variable.  It may be anywhere from a few weeks to more than 1 year.  In addition, any changes that do occur may not be noticed for additional months or years.  Thus, it is often extremely difficult or impossible to figure out who infected whom.

There is both some bad and a lot of good news about this infection.

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The Bad News:

• HPV infection is extremely common.
  - It is estimated that at any given time 20-40 million Americans are infected.
  - Over a typical college career approximately 60% of sexually active women will become infected.  While it is assumed that a similar number of men are also infected, there are no good statistics as it is harder to test for HPV in men than women.
  
• Cancer of the cervix is almost always caused by HPV infection (high risk strains).
  
• Since HPV is transmitted by close genital contact, condoms provide some, but  imperfect, protection against infection.
  
• There is no test that can guarantee that anyone (particularly men) are not infected with HPV.
  
• HPV infection is particularly serious in those with an immune disorder (e.g. HIV/AIDS)
• HPV can be contracted by one person, cause absolutely no symptoms, and, months or years later, be transmitted to a new partner.

   

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The Good News:

• The large majority of people cure themselves (usually without ever knowing that they had been infected).  Average length of time from infection to cure is about 8 months.  Most times, if low risk HPV is detected in a woman without symptoms, we would recommend only "watchful waiting" as treatment.
  
• Early changes on the cervix which could lead to cancer are nearly always discovered on Pap tests.
  
• Warts, if they develop, are usually treatable.
  
• The HPV virus is so common that it can almost be considered normal to have it.
  
• HPV, as well as other STIs, is no more common at Rutgers University than other similar institutions.

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Symptoms:

• Often none at all.  Rarely painful or itchy.
  
• Warts - may not be present but when they are they tend to grow in the genital area in both men and women.  In addition, they may be seen in or around the urethra, anus and sometimes the mouth, lips, tongue and throat.  The warts may vary in appearance but typically look like this (warning, clicking on link will bring up graphic pictures).

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Diagnosis:

• In Women - Diagnosed either by a Pap test which suggests HPV and is then confirmed by a second test, or by the presence of visible warts.
  
• In Men - May only be diagnosed if warts can be seen.  A vinegar solution is sometimes applied to the skin to help visualize flat warts.
  
• Pictures of genital warts (warning - graphic pictures).

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Potential Complications:

• Cancer of the cervix is almost always associated with high risk strains of HPV (although the vast majority of those with HPV infection never develop cancer).
  
• It is less clear whether other types of cancer (e.g. penile, anal) are at any increased risk.
  
• Rarely wart growth may block the urethra, interfering with urination.

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Treatment:

• Most people "cure" themselves - usually without ever knowing that they were infected.  This would be the usual treatment for those women found to have HPV on routine testing or with mildly abnormal Pap smears.
  
• There are several treatment options for treating HPV/warts.  These range from prescription creams (effective but expensive), to burning the warts with acid or by laser, freezing them with liquid nitrogen, or surgical removal.  Treatment by any of theses means often, but not always, leads to a cure.  Except for laser and surgical therapy, all of these treatment options are available at RUHS.
  
• Some women will need to go for a test called colposcopy to take a better look at the cervix.  During this test, treatment to the cervix is often done.

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Prevention:

• Only total absence with of skin to skin contact with an infected individual will insure protection.  Condoms (male and female) and dental dams offer some, but limited protection against this infection.
  
• Annual Gyn exams help to find any evidence of infection and the Pap test that is done periodically will check for early changes associated with HPV infection.

Vaccination:

• The vaccine
  • In June 2006, a HPV vaccine (Gardasil®) was approved by the FDA.  This vaccine protects against 4 strains of HPV (6, 11, 16, 18) that are responsible for the majority of genital warts and about 70% of cervical cancers.
• Protection it offers
  • Helps protect against the following diseases caused by HPV:
    • Cervical cancer.
    • Abnormal and precancerous cervical and/or vaginal lesions.
    • Genital warts.
• Limitations
  • Vaccination will help prevent infection with HPV, but will not treat an infection that is already present.  Once infected with a strain of HPV, immunity to that strain typically develops.  However, even in someone already infected with HPV, the vaccine may still make sense as it can protect against other strains of HPV.
  • The vaccine protects against the most common strains of HPV, but not others.
  • Since not all strains are covered, regular gyn exams and Pap smears are still necessary.
• Administration and side effects
  • A total of three shots given over six months (0, 2, 6 months).
  • Side effects are typically mild (local pain or redness, low grade fevers, nausea, dizziness)
• Who is it recommended for?
  • Girls/women between the ages of 9-26
  • While there is an advantage if it is given before sexual activity has begun (to insure no prior infection with HPV), there is still a benefit in giving to women who may have already been infected with HPV as it will protect against other strains.
• What about men?
  • Gardasil® is currently only recommended in girls/women.  Studies are looking at its efficacy in boys/men now.
• Availability/cost
  • RUHS-NB/P does stock Gardasil® and is able to provide to students.
  • This is an expensive vaccine (price fluctuates, but the series will typically cost around $400).
  • Many insurances will cover the cost – some will allow for the vaccine to be given at Rutgers, others will insist it be given at your own doctor’s office. Check with your insurance carrier.

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Rutgers and HPV: 

• Rutgers University has about the same incidence of HPV (and other STIs) as any other similar university or other groups of sexually active young adults.
  
• Rutgers University Health Services has been at the forefront of medical studies to determine how frequent HPV occurs and what the natural history of HPV is.  In fact, the New England Journal of Medicine (the most prestigious journal in medicine) published research that largely originated at Rutgers.  This publication received a lot of publicity at the time and may have fed a misconception that HPV or other STIs are more common at Rutgers.  More information on the Rutgers HPV study.