Introduction

Rohan (pseudonym) noticed small skin growths in his genital area and was worried that it is genital wart. He visited his provider to understand what needs to be done. On examination, his doctor reassured him that they were mostly heat boils. In this process, he was able to discuss his sex life, clarify doubts he had regarding certain sexually transmitted infections. He also understood that genital warts that are caused by HPV can be prevented using multiple strategies including vaccination which he had earlier thought is for cis-women only. He made an appointment for the next week for vaccination. 

Human Papillomavirus (HPV) infection is considered to be one of the common sexually transmitted infections across the globe and the majority of the infections are asymptomatic and go away on their own without any health effects. The infection is mostly dreaded due to its potential to cause specific cancers – cancers of the cervix, anus, penis, vulva, vagina, head, or neck. Cervical cancer is the second most common type of cancer in women aged 15-45 yrs of age in India and more than 95% of cervical cancer is caused by sexually transmitted HPV. Similarly persistent infection with certain specific types of HPV also has the risk of causing anogenital, penile, oral cancers and gay, bisexual men, transgender individuals are disproportionately affected by these. 

But it is important to understand that not all infections by HPV have the risk of causing cancers. Moreover there are several strategies that individuals can adopt to reduce the risk of acquiring HPV infection or its complications. While the public health measures heavily focus on preventive strategies like vaccination, screening procedures like PAP smear for adolescent and young cis-women, we need equal attention paid to gay, bisexual men, trans individuals in order to prevent the effects of the infection.

In this article, we shall delve into understanding this infection and how to protect ourselves better from the infection or its effects.  

What HPV infection can look like and its spread

More about the virus and its transmission

Human Papillomavirus (HPV) infection is a viral infection that affects the skin and mucous membranes of humans. Human Papillomaviruses is a family of viruses that can cause infections which might result in skin and mucosal warts, and less commonly specific cancers. There are around 150 types of HPV identified among which at least 40 are known to infect the anogenital areas. 

The most common mode of transmission of HPV infection is through sexual route – during vaginal or anal or oral sex with someone who has the virus. The virus can get transmitted by skin-mucosa contact or close skin-skin contact of anogenital area during sex even if the sexual activity isn’t penetrative in nature or through sharing sex toys. There is also evidence that deep kissing might have a risk of transmission of HPV. Transmission through all these routes can occur from a person infected with the virus even if they are asymptomatic. Thus adopting preventive measures becomes important to reduce the risk of getting the infection. There are also certain types of HPV viruses that cause common skin warts in other than anogenital areas – like hands, feet etc which are mostly transmitted through non-sexual routes among children and adults through skin-skin contact eg: HPV types 1, 2, 3, 4 etc. 

Possible ways in which the infection can present

All persons who are sexually active will have the risk of getting the infection as it is a very common one. But the majority of the HPV infections are harmless – that cause no symptoms and are cleared by the immune system without causing any health problems within 6-24 months. 

Some types of HPV can cause skin or anogenital warts eg: HPV types 6, 11, 32 and a few types of HPV are considered “high-risk” as they have the potential to cause cancer, including cervical, anal, penile, vaginal, and throat cancer. For example: HPV types 16, 18, 31, 33

Anogenital warts: Anogenital warts are small, pointy growths in the genital or anal area. More rarely they also occur in the mouth. 90% of these are caused by non-oncogenic (non-cancer forming) types of HPV – 6 and 11. But a few high-risk types of HPV can also cause anogenital warts. Hence it is important to get yourself examined if you find any such lesions so that it can be detected early and complications can be prevented. Most anogenital warts do not hurt or cause any other symptoms, but some can itch or be painful. They can appear around the opening of the vagina, under the foreskin of penis, or shaft of penis, around the anus, scrotum, cervix.  The Anogenital warts are treated with ointments, laser surgery, excision or icing. Even after a successful therapy, relapses can occur. This is why follow-up examinations over longer periods of time are necessary.

Cancer: As stated earlier, not all infections from various types of HPV viruses have a risk for cancer. It is dependent on the types of viruses and the persistence of infection. Certain viruses that have been known to have high-risk to cause various cancers include types 16, 18, 31, 33 etc with 16 and 18 being more common that can cause cancers of cervix, anus, penis, vulva, vagina, head, or neck. Hence, most of the vaccines target those HPV types that commonly cause anogenital warts and have a high risk for cancer. Even infections with these doesn’t directly mean that it will result in cancers. There are a number of factors that can contribute to this. Most of the infections caused by HPV including these high-risk viruses are self limiting, where the persons can clear the infections from their bodies spontaneously. Only when the infection persists they can have the potential to develop the above cancers further depending on the types of HPV. Immunocompromised status can make a person prone to having persistent infection, hence vaccination for HPV is particularly recommended for people living with HIV and advised to undergo regular screening procedures for early detection of infection. Other conditions that can be considered as immunocompromised status is if a person is undernourished, having diabetes, taking immunosuppressant therapy for any medical conditions like post-transplant etc. In addition to the type of virus and persistence of infection, cigarette smoking has shown evidence to increase the risk for the infection to cause cancerous changes. 

Most of the awareness campaigns including the recent media coverage focus on cis-women and the issue of cervical cancer when it comes to HPV infection. While that is certainly a public health issue, providers, public health professionals and the public have to keep people of all genders in mind as HPV infection can impact anyone’s life and prevention and early detection strategies and save people’s lives. 

Prevention strategies

Practising safe sex through consistent and correct condom use can help reduce the risk of acquiring most of the STIs including HPV. But since the transmission of HPV infection occurs not only through mucosal contact but also through close skin-skin contact with the anogenital area during intimate sexual activities, condoms may not completely provide protection against HPV infection. Hence one needs to consider other strategies in combination – like vaccination, screening and early detection to effectively prevent the infection and its effects especially from the types of viruses that can cause anogenital warts or cancers. Presence of other STIs can also increase the risk of transmission of HPV infection and so screening for other common STIs and prevention of those are also part of the strategy to prevent HPV infection itself.  

Vaccination

Vaccination can protect you against infection with major virus types especially the strains that have the risk to cause anogenital warts and cancers. The vaccines are known to have 99% efficacy in preventing persistent infection, anogenital warts, and pre-cancerous or cancers of cervix, anus, penis by the types of HPV that are present in the vaccine provided the person doesn’t already have the infection. 

Vaccination is most effective if one takes it before they begin to be sexually active in their life. This is because they are effective in preventing infection from the above types of HPV among those who haven’t been infected before. There is no evidence that vaccines prevent the effects of the infection once the person already has the infection at the time of taking the vaccine. But if the person has a different type of HPV infection other than the types in the vaccine, this doesn’t reduce the efficacy of the vaccine, it still works. The recommended age is 9-14 yrs but routine vaccination is still recommended till the age of 26 yrs for persons of any sex and gender. Beyond this age, for adults of 27-45 yrs age, whether you would benefit from the vaccine can generally be decided through shared decision making with a provider. The vaccines are not licensed for people more than 45 yrs of age. People who are living with HIV especially if the CD4 count is low will have higher risk for the infections to become persistent and the risk for cancerous changes and so the vaccine is highly recommended. Similarly other conditions that might make one immunocompromised like those persons on immunosuppressant therapy will benefit more from the vaccine and is recommended. HPV vaccine is not recommended during pregnancy. Vaccine can be taken irrespective of previous history of having anogenital warts or tests results –  HPV test or PAP smear results. People with multiple sexual partners have higher chances of acquiring HPV infection and so vaccination can be beneficial. The vaccine can also be taken by trans individuals who may be on gender-affirming hormonal therapy or have undergone gender-affirmative procedures. So, vaccinate yourself and your partner/s to prevent HPV infections.

In India, there are four vaccines currently available – 

1) Cervarix (containing HPV types 16, 18)

2) Gardasil-4 (containing HPV types 6, 11, 16, 18) 

3) Gardasil-9 (containing HPV types 6, 11, 16, 18,  31, 33, 45, 52, and 58) 

and the more recent one 

4) Cervavac (containing HPV types 6, 11, 16, 18). 

All the currently available vaccines protect against the high-risk types 16 and 18 and a few also cover types that cause most of the anogenital warts – 6 and 11. The reason for the vaccines to have these HPV types in them is because 6 and 11 cause >90% of the anogenital warts and 16, 18 are the types responsible for most of the HPV-related cancers (cancers of cervix, anus, penis etc). For eg: HPV 16 and 18 cause 66% of cervical cancers and 75-80% of the HPV related anal cancers. In the Gardasil-9 one, additionally 5 other types are covered (within the 9 types in the vaccine) covering an additional 15% of the cancers. Although these vaccines have high efficacy in preventing the infections with the types of HPV in the vaccine, there are a few other uncommon HPV types that the vaccines don’t contain and hence won’t protect against. Thus, continuing to practise safe sex and other preventive measures like regular screening are important. 

Dosing of the vaccine and starting age at administration varies slightly between each of these vaccines. Generally 2 doses of vaccine is given with a gap of 6-12 months if the vaccine was started before the age of 15yrs and 3 doses if started after the age of 15 yrs or for those who are considered immunocompromised (with an interval of 1-2 months and 6 months). 

None of the above vaccines are being provided in the government health system and so the cost of vaccines are unfortunately having to be borne by individuals and obtained in private facilities. Cost of each dose of the vaccine ranges between INR 2000-9000. The central Government in India has recently announced that they would encourage HPV vaccination among girls aged between 9 and 14 years and the National Technical Advisory Group for Immunization (NTAGI) has recommended introduction of HPV Vaccine in the Universal Immunization Programme (UIP) but this is yet to be acted upon. Even when acted upon the focus is on girls and not all youth of various genders at risk of the infection, especially on gay, bisexual, transgender individuals who may face disproportionate risk but not get the attention needed. 

Most of the private facilities especially with dermatology/gynaecology departments, or those who care for Sexual health, STIs will have HPV vaccination services. 

Screening, testing, and early detection as prevention

Apart from practising safe sex and vaccination, another key thing to do is regular screening and early detection of the infection so as to prevent the chance of it leading to precancerous or cancerous changes especially because most people who have the infection do not have symptoms and don’t realise it. 

Screening and diagnostic tests for HPV infection include – visual examination for anogenital warts, cervical mucosa, visual inspection with acetic acid, PAP smear to see the cells in cervix/anal lining, HPV-DNA PCR testing, co-testing (both PAP smear+HPV test), biopsy of the skin growths in special cases if needed. Most of the tests are targeted at detecting the virus types that have a high-risk for causing cancers – like HPV 16 and 18 or to detect any cancerous/ precancerous change in the cells of the anogenital mucosa with the intention of preventing cancers. Tests are not targeted to detect infections with all HPV types as most of them are harmless and get cured on their own. Antibody based tests are not useful in the case of HPV infection as a positive result may mean current or past infection and won’t contribute towards the treatment plan.  

PAP smear is a simple test done by a doctor or nurse to check for signs of precancerous or cancerous changes in the cells of the mucosal lining. Although it is popularly known for its use to detect such changes in cervix bearing persons, it can as well be used to screen for anal cancers among gay/bisexual men or anyone at risk of transmission of HPV through anal sex. During the test, they use a small tool to collect a few cells from the cervix/anus. These cells are then sent to a lab to be examined under a microscope. Pap smears can help detect any abnormal changes in the cells early on, which allows for timely treatment and prevention of cancer. It’s a quick and painless procedure. Official guidelines exist that recommend regular screening using PAP smear for persons with cervix – every 3 yrs starting from the age of 25 yrs till 65 yrs in good resource settings. In resource limited settings, instead of PAP smear another test – visual inspection with acetic acid is done to detect any abnormality every 5 yrs starting from the age of 30 yrs.  Although there are no official guidelines on how frequently the screening has to be done for anal mucosa, experts have opined that once in 1-2 yrs for people living with HIV and once in 3 yrs for those without HIV is recommended. 

HPV testing is done to detect high-risk virus types using the swabs from the cervical or anal region. If it is done along with PAP smear, then it is termed “co-testing” and this can be done once in 5 yrs. PAP smear testing currently in most places is more accessible and cheaper than the HPV tests and so most people can rely on that for regular screening.

Management of HPV infections

Most people with infections are asymptomatic and the infection may resolve on its own and may not need treatment. There are no specific antiviral drugs that are used against this infection. But symptoms like genital warts, precancer lesions are treated. 

For anogenital warts – the treatment would mainly involve reduction of symptoms and removal of warts. Some may even be left without treatment as most can resolve on their own. Treatment is mostly dependent on the size of the warts, number, cost involved, and other symptoms associated with it and the provider should discuss and decide the treatment options with you. Options include – application of creams, solutions, gel, ointment by self which will enhance the immune system to fight the infection and resolve the warts or in certain situations cryotherapy with liquid nitrogen or cryoprobe is done by the provider. Sometimes even surgical removal is recommended by laser/ cutting it/ electrosurgery. Most warts once taken care of don’t reoccur. Persons who have genital warts externally visible will also be examined to see if there are any lesions internally – in the cervix/anal region. Partners can also be examined for any warts and should be counselled. Generally HPV testing isn’t necessary for people with warts or their partners. Diagnosis is done by examination. But regular screening as described above can be continued. 

During regular screening using PAP smear or HPV or co-testing, if abnormal cells are detected, treatment procedures like laser therapy, cryotherapy (freezing the area), applying medicines, Loop electrosurgical excision procedure (LEEP) are done in order to arrest this process so as to prevent it from becoming cancerous. LEEP involves using a wire loop heated by electric current to remove cells and tissue from the genital tract. In this process, biopsy testing might be done where a small chunk of the tissue is taken to examine it in detail. All these procedures can prevent the person from getting cancer thus underscoring the importance of screening and early detection for HPV infections. 

Conclusion

HPV is a common infection that most people who are sexually active encounter. Although the transmission occurs easily, one can prevent oneself from the common harmful types of HPV at least using multiple strategies of practising safe sex, vaccination, regular screening and early detection, and open communication with partner/s. Being informed of the importance of each of them can take you a long way in terms of avoiding stress and having a safe and pleasurable sex life. 

Acknowledgments:

I would like to thank Dr Akshay S Dinesh for having discussions with me that has helped me shape this article. 

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About the Author:

Dr. Swathi SB

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