Human Papillomavirus (HPV) is the most common sexually transmitted disease (STD) in the United States. About 6.2 million Americans become infected with genital HPV every year and over 50% of all sexually active men and women become infected with HPV at some time in their lives. One study found HPV in 77 percent of HIV+ women.

There are about 30 types of HPV that are transmitted by sexual activity. These types can infect the genital area – the vulva, vagina, cervix, anus, and penis. Different types of HPV cause warts or abnormal cell growth (dysplasia). More than 95% of cervical cancers have been shown to be associated with HPV types 16, 18, 31, 33, and 45. HPV may also cause cancer in the vagina, vulva, and anus.

HPV is transmitted easily through skin-to-skin contact during vaginal or anal sex with someone who has the infection. Condoms do not totally prevent transmission. Many people who have HPV don’t know it because they have no symptoms. However, it can still be passed on to someone else.

Because HPV is a virus, there is no cure for it. However, the conditions or symptoms of HPV are treatable. A vaccine called Gardasil was recently approved for the prevention of four types of HPV: types 6, 11, 16, and 18.

Certain types of HPV will cause external genital warts on the vulva, penis, or around the anus. Warts can appear anywhere from a few weeks to a few months after you are exposed to HPV.

Symptoms:

• Red, pinkish, or white warts that look like growths, bumps, or small cauliflowers

Diagnosis:

• Doctor can usually identify genital warts by looking at them
• Sometimes a biopsy is done (a sample of the suspected wart is cut off and examined under a microscope)

Treatment:

• Since HPV is a virus, there is no cure for it, but it can be treated by removing the wart
• The following treatments must be done in the doctor’s office:
  - TCA (trichloracetic acid) treatment – a chemical is applied to the surface of the wart on a weekly basis to break it down
  - Cryotherapy – freezing off the wart with liquid nitrogen (may mask future problems*)
  - Electrocautery – burning off the wart with an electrical current
  - Laser therapy – using an intense light to destroy the wart
  - Excision – cutting the wart out
• Some treatments can be done at home with prescription creams (these should not be used by pregnant women)
• Warts can reappear after successful treatment

Many HIV+ women, especially those with low CD4 cell counts, may respond poorly to standard therapies. Several different HPV treatments may be needed.

Certain types of HPV can cause abnormal cells to form. This is called dysplasia. Dysplasia is more common in women with advanced HIV disease and low CD4 cell counts. It is often more severe and difficult to treat than in HIV- women.

The main place dysplasia occurs is on the cervix. Other less common areas are the vagina, vulva, and anus. Dysplasia is not cancer, but if left untreated, it can develop into cancer.

Cervical cancer can be life threatening. It is one of the few AIDS-defining conditions specific to women. However, it can be prevented through early diagnosis and treatment.

Symptoms:

• Many women do not experience symptoms
• In very advanced stages, a woman may experience pain, vaginal discharge, and bleeding between periods

Diagnosis:

• Pap smears (a Pap smear is a screening test your doctor does to check for changes in the cervix)
• An abnormal Pap smear can indicate inflammation, infection, dysplasia, or cancer
• If you have an abnormal Pap, you may need a colposcopy (an exam of your cervix using a microscope to look at the tissue more closely)
• HIV+ women are 10 times more likely to have abnormal Pap smears than HIV- women
• The Centers for Disease Control (CDC) recommend that:
  - HIV+ women have a complete gynecological examination, including a Pap smear, when they are first diagnosed or when they first seek prenatal care
  - HIV+ women have another Pap six months later
  - If both tests are negative, yearly screening is recommended
  - Women who have symptomatic HIV infection or who have had dysplasia in the past should receive a Pap smear every six months
• A new HPV test is starting to be used in conjunction with Pap smears to detect cancerous and precancerous conditions

Treatment for dysplasia:

Most treatments for dysplasia focus on destroying the abnormal tissue so that it doesn't progress to cancer.

• Electro-cauterization
• Laser therapy
• Cold-knife cone biopsy
• Loop electric excision procedure (LEEP)
• Cryotherapy (may mask future problems*)
• In cases of mild dysplasia, the doctor may just monitor the cervix by colposcopy, repeat Pap, or HPV test

Treatment of cervical cancer:

• Surgery
• Radiation

*Recent studies have raised concerns about cryotherapy, which involves freezing off the warts or abnormal cells. It can cause normal tissue to heal over deeper areas of dysplasia, and therefore future screenings may appear normal while abnormal tissue is actually growing below the healing tissue.

Certain strains of HPV may also cause dysplasia and cancer in the anus. Although the risk of developing dysplasia is higher among men who have sex with men, women are also at risk, especially those with HIV infection or a history of anal intercourse.

Symptoms:

• May be no symptoms
• Anal bleeding, irritation, itching, or a burning sensation
• In very advanced stages, there may be abscesses, lumps, ulcers, and anal discharge

Diagnosis:

• Anal Pap smear
• If you have an abnormal Pap, you may need an anoscopy (an exam of the anus using a microscope to look at the tissue more closely)
• Physical examination
• It is important to ask your doctor to perform these tests on a regular basis

Treatment:

• Same as treatment for dysplasia and cervical cancer (see section above)

HIV+ people are more likely to be infected with HPV than HIV- people. One study found HPV in 77 percent HIV+ women. Because of immune suppression, HIV+ women are more likely to have:

• Chronic HPV infection
• Infection with the HPV strains more likely to cause cancer
• HPV in both the cervix and anus
• Several strains of HPV at once
• Reactivated HPV infections that were previously under control
• HPV that responds poorly to standard therapies – multiple treatments using different methods may be needed

In June, 2006, the Food and Drug Administration (FDA) approved a vaccine called Gardasil for prevention of cervical cancer. The vaccine is approved for girls and women who are 9 - 26 years of age. Gardasil is effective in preventing cervical cancer caused by HPV types 16 and 18, which cause approximately 70% of all cervical cancers and in preventing infection with HPV types 6 and 11, which cause approximately 90% of all genital warts. Gardasil is a recombinant vaccine (contains no live virus) that is given as 3 injections over a 6-month period. However, women who are already infected with HPV are not protected by the vaccine. Also, Gardasil does not protect against less common HPV types not included in the vaccine. Therefore, doctors still recommend regular Pap smears to detect changes in the cervix (dysplasia) before they become cancerous, so that women can receive treatment before cervical cancer develops. When dysplasia is detected and treated early, cervical cancer can be prevented.

HPV can be very serious for HIV+ people. Since there are frequently no symptoms, regular monitoring by your doctor and gynecologist is the best way to ensure that any problems are detected and treated before they progress.

1		Bartlett, J. G. (2006). Human Papillomavirus. Medscape Infectious Diseases Expert Reviews and Commentary: Retrieved July 2006 from http://www.medscape.com/viewarticle/540607 (free membership required to access article).
2		The Body. (2005). Gynecological conditions and HIV/AIDS: Retrieved July 2006 from http://www.thebody.com/pinf/gyn_conditions.html.
3		Food and Drug Administration and the Office of Women’s Health. (2006). HPV (Human Papillomavirus): Retrieved July 2006 from http://www.fda.gov/womens/getthefacts/hpv.html.
4		Merckmedicus. (2006). Patient handout Human Papillomavirus (HPV).
5		Panther, L. A., et. al. (2005). Spectrum of Human Papillomavirus-related dysplasia and carcinoma of the anus in HIV-infected patients. AIDS Reader 15(2): 79-91.