Human Papillomavirus HPV Genital Warts F Iraji MD

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Human Papillomavirus (HPV) Genital Warts F. Iraji MD

Human Papillomavirus (HPV) Genital Warts F. Iraji MD

A human papillomavirus (HPV) is a virus that infects the epidermis and mucous membranes.

A human papillomavirus (HPV) is a virus that infects the epidermis and mucous membranes. Over 130 HPV Types • Lifecycle somewhat unknown. • Several months to years may elapse before the abnormal growth of cells •

Human Papillomavirus (commonly called Genital Warts) Human Papillomavirus (HPV) is a virus that can

Human Papillomavirus (commonly called Genital Warts) Human Papillomavirus (HPV) is a virus that can cause various disease states including “genital” or “venereal” warts Papillomaviruses are a complex group of DNA tumor viruses. They can cause benign growths (papillomas), cancers, or more commonly, transient infections HPV infection is causally associated with cervical cancer ; other genital cancers including anal, penile, vulvar, and vaginal cancers may have HPV as co-factor

Human Papillomavirus Cervical Cancer

Human Papillomavirus Cervical Cancer

HPV Prevalence Most common STD – Yearly incidence of 6. 2 million – 20

HPV Prevalence Most common STD – Yearly incidence of 6. 2 million – 20 million currently infected – 80 million infected at least once between the ages of 15 -49 An estimated 9. 2 million sexually active adolescents and young adults 15 -24 years of age are infected with genital HPV An estimated 5%-30% of people infected with genital HPV are infected with multiple types of the virus 316, 000 initial visits to physicians’ offices (2004)-genital wart diagnosis

GENITAL HPV INFECTION 1% 4% 10% 60% 25% 1. 4 MILLION 5 MILLION 14

GENITAL HPV INFECTION 1% 4% 10% 60% 25% 1. 4 MILLION 5 MILLION 14 MILLION 81 MILLION 34 MILLION VISIBLE WARTS Subclinical (Colposcopy) Subclinical (DNA testing) Prior infection (+ antibodies) No prior/current infection

Epidemiology of HPV and Cervical Cancer Over 99% of cervical cancers have HPV DNA

Epidemiology of HPV and Cervical Cancer Over 99% of cervical cancers have HPV DNA detected within the tumor 70% of cervical cancer is caused by one of two types of HPV, 16 or 18 The quadrivalent HPV vaccine protects against Types 6, 11, 16 and 18

HPV Small virus – 130 types – Low-risk e. g. 6, 11 – High-risk

HPV Small virus – 130 types – Low-risk e. g. 6, 11 – High-risk e. g. 16, 18 Associated with various disease from skin warts to cervical cancer Transmission via skin-to-skin/sexual Most common STD

Pathogenesis HPV Genotyping System Genital HPV types are generally characterized in terms of oncogenic

Pathogenesis HPV Genotyping System Genital HPV types are generally characterized in terms of oncogenic potential. Low-risk types (nononcogenic types) – Most genital warts caused by HPV types 6 and 11 – Recurrent respiratory papillomatosis associated with HPV types 6 and 11 High-risk types (oncogenic types) – HPV types 16 and 18 found in 70% of cervical cancers – Most women with high-risk HPV infection have normal Pap test results and never develop cellular changes or cervical cancer. 13 13

Pathogenesis Pathology HPV infects the basal cell layer of stratified squamous epithelium and stimulates

Pathogenesis Pathology HPV infects the basal cell layer of stratified squamous epithelium and stimulates cellular proliferation. Affected cells display a broad spectrum of changes, ranging from benign hyperplasia, to dysplasia, to invasive carcinoma. 14

Pathogenesis Natural History of HPV Most genital HPV infections are transient, asymptomatic (subclinical), and

Pathogenesis Natural History of HPV Most genital HPV infections are transient, asymptomatic (subclinical), and have no clinical consequences in immunocompetent individuals. Time to development of clinical manifestations is variable. Median duration of new cervical infections is 8 months, but varies. – 90% of infections clear within 2 years – Gradual development of an effective immune response is the likely mechanism for HPV DNA clearance. 15

Pathogenesis Natural History of HPV-continued Persistent HPV infection – Not cleared by the immune

Pathogenesis Natural History of HPV-continued Persistent HPV infection – Not cleared by the immune system – Characterized by persistently detectable typespecific HPV DNA – Persistent oncogenic HPV infection is most important risk factor for precancerous cervical cellular changes and cervical cancer. 16

How does HPV cause cancer? HPV infection Persistent HR HPV infection Normal epithelium HPV

How does HPV cause cancer? HPV infection Persistent HR HPV infection Normal epithelium HPV clearance No lesion > 80% CIN 10 -20+ years Invasive carcinoma HPV clearance & regression dependent on age, degree of CIN lesion & immune status

Strength of Association Relative Risk Carcinogenic Agent > 500 High Risk HPV and cervical

Strength of Association Relative Risk Carcinogenic Agent > 500 High Risk HPV and cervical cancer - Philippines, Costa Rica, Bangkok 50 -100 Hepatitis B virus and liver cancer - Taiwan, Greece 20 Hepatitis C virus and liver cancer - Italy, Spain 10 Cigarette smoking and lung cancer

2 opportunities to prevent cervical cancer Prophylactic HPV vaccination Normal cervix HPV infection Cervical

2 opportunities to prevent cervical cancer Prophylactic HPV vaccination Normal cervix HPV infection Cervical screening & treatment Precursor disease – Cervical Intraepithelial Neoplasia (CIN) Cervical cancer

Questions?

Questions?

Epidemiology of HPV and Cervical Cancer Over 99% of cervical cancers have HPV DNA

Epidemiology of HPV and Cervical Cancer Over 99% of cervical cancers have HPV DNA detected within the tumor 70% of cervical cancer is caused by one of two types of HPV, 16 or 18 The quadrivalent HPV vaccine protects against Types 6, 11, 16 and 18

Risk Factors for Acquiring a Genital HPV Infection Young age (less than 25 years)

Risk Factors for Acquiring a Genital HPV Infection Young age (less than 25 years) Multiple sex partners Early age at first intercourse (16 years or younger) Male partner has (or has had) multiple sex partners

HPV Transmission Direct skin-to-skin contact – Usually, but not always sexual contact Infected birth

HPV Transmission Direct skin-to-skin contact – Usually, but not always sexual contact Infected birth canal Fomites (very rare) Friction and abrasion are key factors. Difficult to determine how and where infection occurred due to poor standardized tests and variable latency periods.

How is HPV spread? Any kind of sexual activity involving skin to skin genital

How is HPV spread? Any kind of sexual activity involving skin to skin genital contact with an infected person — intercourse isn't necessary. People with HPV may not show any signs or symptoms, so they can pass the virus on without knowing it.

What about oral sex? It can occur in the mouth, throat or respiratory tract

What about oral sex? It can occur in the mouth, throat or respiratory tract It is relatively uncommon It appears to be an inefficient mode for transmission

HPV Incubation Average incubation is 3 weeks to 1 year Possibly years before appearance

HPV Incubation Average incubation is 3 weeks to 1 year Possibly years before appearance of warts or cervical abnormalities Some will be transient and may never be detected

Common Symptoms of Genital Warts in Males & Females The symptoms may include single

Common Symptoms of Genital Warts in Males & Females The symptoms may include single or multiple fleshy growths around the penis, scrotum, groin, vulva, vagina, anus, and/or urethra They may also include: itching, bleeding, or burning, and pain The symptoms may recur from time to time

Clinical Manifestations Genital Warts-Duration and Transmission May regress spontaneously, or persist with or without

Clinical Manifestations Genital Warts-Duration and Transmission May regress spontaneously, or persist with or without proliferation. – Frequency of spontaneous regression is unclear, but estimated at 10– 30% within three months. – Persistence of infection occurs, but frequency and duration are unknown. – Recurrences after treatment are common. 29

Clinical Manifestations Genital Warts and High-Risk HPV High-risk HPV types occasionally can be found

Clinical Manifestations Genital Warts and High-Risk HPV High-risk HPV types occasionally can be found in visible warts and have been associated with squamous intrepithelial lesions (squamous cell carcinoma in situ, Bowenoid papulosis, Erythroplasia of Queyrat, or Bowen’ s disease of the genitalia). The lesions can resemble genital warts. Unusual appearing genital warts should be biopsied. 30

Genital Warts in a Male Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical

Genital Warts in a Male Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides Source: Cincinnati STD/HIV Prevention Training Center

HPV Penile Warts Source: Cincinnati STD/HIV Prevention Training Center

HPV Penile Warts Source: Cincinnati STD/HIV Prevention Training Center

Pearly Penile Papules

Pearly Penile Papules

Vestibular papillomatosis

Vestibular papillomatosis

Intra-meatal Wart of the Penis (and Gonorrhea) Source: Florida STD/HIV Prevention Training Center

Intra-meatal Wart of the Penis (and Gonorrhea) Source: Florida STD/HIV Prevention Training Center

Circumcision and HPV Risk for penile cancer May influence the risk of HPV acquisition,

Circumcision and HPV Risk for penile cancer May influence the risk of HPV acquisition, transmission and cervical cancer

Female Genital Warts Source: CDC/NCHSTP/Division of STD, STD Clinical Slides

Female Genital Warts Source: CDC/NCHSTP/Division of STD, STD Clinical Slides

Clinical Manifestations Perianal Warts Source: Seattle STD/HIV Prevention Training Center at the University of

Clinical Manifestations Perianal Warts Source: Seattle STD/HIV Prevention Training Center at the University of Washington/ UW HSCER Slide Bank 39

Clinical Manifestations Vulvar Warts Source: Reprinted with permission of Gordon D. Davis, MD. 40

Clinical Manifestations Vulvar Warts Source: Reprinted with permission of Gordon D. Davis, MD. 40

HPV Warts on the Thigh Source: Cincinnati STD/HIV Prevention Training Center

HPV Warts on the Thigh Source: Cincinnati STD/HIV Prevention Training Center

Perianal Warts Source: Cincinnati STD/HIV Prevention Training Center

Perianal Warts Source: Cincinnati STD/HIV Prevention Training Center

Complications of Genital Warts (if untreated) It may destroy body tissue around the genitals

Complications of Genital Warts (if untreated) It may destroy body tissue around the genitals and anus For pregnant women – Delivery complications or need for C-section – Juvenile Onset Recurrent Respiratory Papillomatosis (JO-RRP)

Testing & Treatment for Genital Warts Can be detected in a clinical exam; Can

Testing & Treatment for Genital Warts Can be detected in a clinical exam; Can be treated by removing the warts; The virus cannot be removed, so the warts may grow back.

Clinical Manifestations Cervical Cellular Abnormalities Usually subclinical Lesions associated with these abnormalities can be

Clinical Manifestations Cervical Cellular Abnormalities Usually subclinical Lesions associated with these abnormalities can be detected by Pap test or colposcopy, with or without biopsy. Can be caused by HPV Low-grade lesions often regress spontaneously without treatment. 47

Clinical Manifestations Classification of Cervical Cellular Abnormalities 2001 Bethesda System Atypical Squamous Cells (ASC-US

Clinical Manifestations Classification of Cervical Cellular Abnormalities 2001 Bethesda System Atypical Squamous Cells (ASC-US and ASC-H) are cells that do not appear to be completely normal – Atypical Squamous Cells of Undetermined Significance (ASC–US) Changes are often caused by HPV infection. Changes are usually mild. – Atypical Squamous Cells cannot exclude a High. Grade Squamous Intraepithelial Lesion (ASC–H). Changes are more likely to be associated with precancerous abnormalities than ASC-US. 48

Clinical Manifestations Classification of Cervical Cellular Abnormalities-continued Low-grade squamous intraepithelial lesion (LSIL) – Usually

Clinical Manifestations Classification of Cervical Cellular Abnormalities-continued Low-grade squamous intraepithelial lesion (LSIL) – Usually transient, caused by HPV infection High-grade squamous intraepithelial lesion (HSIL) – – Generally changes due to persistent infection with a high-risk HPV type Lesions associated with HSIL have a higher risk for progression to cervical cancer. 49

HPV Diagnostic Techniques History Visual exam Pap smears DNA testing

HPV Diagnostic Techniques History Visual exam Pap smears DNA testing

Diagnosis of Genital Warts Diagnosis is usually made by visual inspection with bright light.

Diagnosis of Genital Warts Diagnosis is usually made by visual inspection with bright light. Consider biopsy when – – Diagnosis is uncertain; Patient is immunocompromised; Warts are pigmented, indurated, or fixed; Lesions do not respond or worsen with standard treatment; or – There is persistent ulceration or bleeding. 51

Diagnosis of Genital Warts-continued Use of type-specific HPV DNA tests for routine diagnosis and

Diagnosis of Genital Warts-continued Use of type-specific HPV DNA tests for routine diagnosis and management of genital warts is not recommended. Application of acetic acid to evaluate external genitalia is not routinely recommended due to its low specificity. Acetowhitening will occur at sites of prior trauma or inflammation. External genital warts are not an indication for cervical colposcopy or increased frequency of Pap test screening (assuming patient is receiving screening at intervals recommended by her healthcare provider). 52

Diagnosis Differential Diagnosis of Genital Warts Other infections – Condylomata lata Tend to be

Diagnosis Differential Diagnosis of Genital Warts Other infections – Condylomata lata Tend to be smoother, moist, more rounded, and darkfield -positive for Treponema pallidum – Molluscum contagiosum Papules with central dimple, caused by a pox virus; rarely involves mucosal surfaces Acquired dermatologic conditions – – – Seborrheic keratosis Lichen planus Fibroepithelial polyp, adenoma Melanocytic nevus Neoplastic lesions 53

Diagnosis Differential Diagnosis of Genital Warts-continued Normal anatomic variants – “Pink pearly penile papules”

Diagnosis Differential Diagnosis of Genital Warts-continued Normal anatomic variants – “Pink pearly penile papules” – Vestibular papillae (micropapillomatosis labialis) – Skin tags (acrochordons) External genital squamous intraepithelial lesions (SIL) – – Squamous cell carcinoma in situ Bowenoid papulosis Erythroplasia of Queyrat Bowen’s disease of the genitalia 54

Diagnosis of Cervical Cellular Abnormalities Cytology (Pap test) – Useful screening test to detect

Diagnosis of Cervical Cellular Abnormalities Cytology (Pap test) – Useful screening test to detect cervical cell changes – Provides indirect evidence of HPV because it detects squamous epithelial cell changes that are almost always due to HPV 55

Diagnosis of Cervical Cellular Abnormalities-continued HPV DNA tests – FDA-approved: To triage women with

Diagnosis of Cervical Cellular Abnormalities-continued HPV DNA tests – FDA-approved: To triage women with ASC-US Pap test results, and As an adjunct to Pap test screening for cervical cancer in women 30 years or older. HPV DNA tests should not be used – In men, – In adolescents <21 years, – To screen partners of women with Pap test abnormalities, – To determine who will receive HPV vaccine, or – STD screening for HPV. 56

Diagnosis of Cervical Cellular Abnormalities-continued Colposcopy – Indication guided by physical exam or Pap

Diagnosis of Cervical Cellular Abnormalities-continued Colposcopy – Indication guided by physical exam or Pap test findings with or without HPV DNA test findings Cervical biopsy – May be indicated if there is/are Visible exophytic lesions on cervix Pap test with HSIL, ASC-H, or other findings www. asccp. org/consensus/cytological. shtml 57

Management General Treatment of Genital Warts Primary goal is removal of warts. If left

Management General Treatment of Genital Warts Primary goal is removal of warts. If left untreated, genital warts may regress spontaneously or persist with or without proliferation. In most patients, treatment can induce wart-free periods. Currently available therapies may reduce, but probably do not eliminate infectivity. Effect of current treatment on future transmission is unclear. 58

Management General Treatment of Genital Warts-continued No evidence that presence of genital warts or

Management General Treatment of Genital Warts-continued No evidence that presence of genital warts or their treatment is associated with development of cervical cancer. Some patients may choose to forgo treatment and await spontaneous resolution. Consider screening persons with newly diagnosed genital warts for other STDs (e. g. , chlamydia, gonorrhea, HIV, syphilis). 59

Management Treatment Regimens Patient-applied and provider-administered therapies are available. Providers should be knowledgeable about

Management Treatment Regimens Patient-applied and provider-administered therapies are available. Providers should be knowledgeable about and have available, at least one patient-applied and one provider-administered treatment. Choice of treatment should be guided by – – – Patient preference, Available resources, Experience of the healthcare provider, Location of lesion(s), and Pregnancy status. 60

Management Treatment Regimens-continued Factors influencing treatment selection include – – – – Wart size,

Management Treatment Regimens-continued Factors influencing treatment selection include – – – – Wart size, Number of warts, Anatomic site of wart, Wart morphology, Patient preference, Cost of treatment, Convenience, and Adverse effects. 61

Papillomavirus Treatment Primary goal for treatment of visible warts is the removal of symptomatic

Papillomavirus Treatment Primary goal for treatment of visible warts is the removal of symptomatic warts Therapy may reduce but probably does not eradicate infectivity Difficult to determine if treatment reduces transmission –No laboratory marker of infectivity –Variable results utilizing viral DNA

HPV Treatment Options Chemical agents Cryotherapy Electrosurgery Surgical excision Laser surgery Imiquimod (Aldara) Defer

HPV Treatment Options Chemical agents Cryotherapy Electrosurgery Surgical excision Laser surgery Imiquimod (Aldara) Defer treatment Natural therapies

Papillomavirus Patient-applied Podofilox (Condylox) 0. 5% solution or gel Apply 2 x/day for 3

Papillomavirus Patient-applied Podofilox (Condylox) 0. 5% solution or gel Apply 2 x/day for 3 days, followed by 4 days of no therapy. Repeat as needed, up to 4 x or Imiquimod (Aldara) 5% cream Apply 1 x/day @ bedtime 3 x/week for up to 16 weeks Sinecatechins 15% ointment*, ** – – Apply ointment 3 times daily for up to 16 weeks. Do not wash off post-application *Safety not established in pregnancy **Safety not established in HIV- or HSV-co-infected individuals

Provider-administered Cryotherapy (liquid nitrogen) *repeat every 1 -2 weeks or Podophyllin resin 10 -25%

Provider-administered Cryotherapy (liquid nitrogen) *repeat every 1 -2 weeks or Podophyllin resin 10 -25% *thoroughly wash off in 1 -4 hrs or Trichloroacetic or Bichloroacetic acid 80 -90% *can be repeated weekly

Papillomavirus Vaginal warts Cryotherapy or TCA/BCA 80 -90% Urethral meatal warts Cryotherapy or podophyllin

Papillomavirus Vaginal warts Cryotherapy or TCA/BCA 80 -90% Urethral meatal warts Cryotherapy or podophyllin 10 -25% Anal warts Cryotherapy or TCA/BCA 80 -90%

Papillomavirus Therapy choice needs to be guided by preference of patient, experience of provider,

Papillomavirus Therapy choice needs to be guided by preference of patient, experience of provider, and patient resources (time and/or money) No evidence exists to indicate that any one regimen is superior An acceptable alternative may be to do nothing but watch and wait; possible regression/uncertain transmission

HPV is INCURABLE Warts can and often do recur after treatment. Virus can remain

HPV is INCURABLE Warts can and often do recur after treatment. Virus can remain in surrounding tissue after warts have been destroyed.

Perinatal complications

Perinatal complications

HPV and Pregnancy No link with premature labor, miscarriage, or other complications Low rate

HPV and Pregnancy No link with premature labor, miscarriage, or other complications Low rate of transmission to baby Range is generally from 0. 4 to 1. 1 cases/100, 000 births C-section is not recommended in most instances

Treatment Regimens

Treatment Regimens

Papillomavirus Treatment in Pregnancy Imiquimod, podophyllin, and podofilox should not be used in pregnancy

Papillomavirus Treatment in Pregnancy Imiquimod, podophyllin, and podofilox should not be used in pregnancy Many specialists advocate wart removal due to possible proliferation and friability HPV types 6 and 11 can cause respiratory papillomatosis in infants and children Preventative value of cesarean section is unknown; may be indicated for pelvic outlet obstruction or if vaginal delivery would result in excessive bleeding

HPV in Neonates Those who develop warts will usually do so within several weeks

HPV in Neonates Those who develop warts will usually do so within several weeks First-born child Juvenile onset recurrent respiratory papillomatosis (JO-RRP) – rare -- 1 per 100, 000 births – types 6 and 11 – occurs up to age four

HPV and Cervical Cancer

HPV and Cervical Cancer

HPV Linked to Cancer Cervical Cancer – – 10, 000 new cases diagnosed/year in

HPV Linked to Cancer Cervical Cancer – – 10, 000 new cases diagnosed/year in the US 3, 000 deaths/year in the US 400, 000 -500, 000 new cases internationally 300, 000 deaths/year internationally, especially in developing countries Single most important factor for cervical cancer – Virtually all squamous cell cervical cancer contain one of 18 types of HPV – The type of HPV that causes visible warts are not linked to cervical cancer Associated with cancer of the penis, anus, vagina and vulva.

HPV DNA Classification Low Risk HPV Types: 6, 11, 40, 42, 43, 44, 54,

HPV DNA Classification Low Risk HPV Types: 6, 11, 40, 42, 43, 44, 54, 61, 72, 73, 81 – types 6 and 11 responsible for 95% of visible warts High-Risk HPV Types: 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 82 High cancer risk: 16 – Most common-50% of cervical cancer High cancer risk: 18 – 10 -12% of cervical cancer *Risk not well established yet: 26, 53, 66, 73

HPV IS ASSOCIATED WITH ANOGENITAL MALIGNANCIES HPV DNA is found in 50 -98% of

HPV IS ASSOCIATED WITH ANOGENITAL MALIGNANCIES HPV DNA is found in 50 -98% of tumors depending on location Oncogenic genes (E 6 and E 7) of high-risk types are expressed in tumors E 6 and E 7 of high-risk types are oncogenic in-vitro Support from many epidemiologic studies

Can a person be re-infected with HPV? There appears to be humoral and probably

Can a person be re-infected with HPV? There appears to be humoral and probably cellular immunity that develops to a specific type of HPV after a person has been infected with it and “has cleared” it. The risk for re-infection with that specific type of HPV appears to be rare. However, a person can be infected with more than one type of HPV

HPV and Cervical Cancer Infection is generally indicated by the detection of HPV DNA

HPV and Cervical Cancer Infection is generally indicated by the detection of HPV DNA Routine Pap smear screening ensures early detection (and treatment) of pre-cancerous lesions Only a small percentage of women infected with genital HPV develop persistent infections – Only women who develop persistent infections are at risk for developing high-grade precancerous changes / cervical cancer – Most women with persistent HPV infection do NOT develop precancerous changes/cervical cancer – The most critical factor for developing cervical cancer is not having routine pap smears

Cofactors for Cervical Cancer Active/passive Cigarette Smoking Chronic inflammation associated with other STDs Long

Cofactors for Cervical Cancer Active/passive Cigarette Smoking Chronic inflammation associated with other STDs Long term use of oral contraceptives High number of live births* • Weakened immune • • • system Multiple sex partners Sex at an early age Nutritional deficiencies Mother who took DES Lack of circumcision of male partner(s) LACK OF SCREENING IS THE MOST IMPORTANT FACTOR

What is the difference between the Pap test, a biopsy and an HPV test?

What is the difference between the Pap test, a biopsy and an HPV test? Pap test finds abnormal cell changes on the cervix Biopsy is when a cluster of cells is removed from the cervix to confirm earlier Pap smear results and rule out cancer HPV test looks for genetic material (DNA) of HPV within cells.

When Is an HPV Test Used? As a follow-up test if the Pap result

When Is an HPV Test Used? As a follow-up test if the Pap result is “borderline” In combination with a Pap test in women at the age of 30 and older False positive results can occur

An HPV test is different than a Pap test or biopsy. This test checks

An HPV test is different than a Pap test or biopsy. This test checks directly for the genetic material (DNA) of HPV within cells, and can detect the types connected with cervical cancer. The test is done in a laboratory, usually with the same cell sample taken during the Pap test. The only commercially available test for HPV is called Hybrid Capture II™, produced by Digene. It is most convenient if the HPV test is done in the laboratory from a cervical cell sample that was taken using a liquid-based Pap test.

When Is an HPV Test NOT Used? If the Pap result shows dysplasia or

When Is an HPV Test NOT Used? If the Pap result shows dysplasia or pre -cancerous changes In women under age 30 unless they have had an ASC-US Pap test result Not on males. The HPV test cannot be used on males. It is only FDA approved to be used on the female's cervix.

HPV Good News 70% of new HPV infections spontaneously clear within one year, and

HPV Good News 70% of new HPV infections spontaneously clear within one year, and as many as 91% clear within 2 years. The median duration of new infections is typically 8 months. The gradual development of an effective immune response is thought to be the likely mechanism for HPV DNA clearance. Women who develop high risk lesions only have a 5% to 15% chance of developing cancer in the absence of treatment.

Non-detectable HPV Currently it is unclear whether genital HPV infections that become “non-detectable” using

Non-detectable HPV Currently it is unclear whether genital HPV infections that become “non-detectable” using standard molecular tests have completely cleared or whether they remain latent in basal cells with the potential for later reactivation Reactivation may explain why some older women in a mutually monogamous relationship can begin to shed genital HPV more likely to be detected in persons with immune system disorders

Key Educational Messages HPV infection is very common, few will develop cervical cancer HPV

Key Educational Messages HPV infection is very common, few will develop cervical cancer HPV is not a reliable indicator of a woman’s sexual behavior or that of her partner Most HPV infections are transient, harmless, have no signs/symptoms, and are cleared by the immune system Persistent HPV infection over many years is necessary but not sufficient for the development of cervical cancer Cervical cancer can be prevented by vaccination and early detection-regular Pap smears

Important Notes Women should continue to receive regular cervical cancer screening (pap smears) –

Important Notes Women should continue to receive regular cervical cancer screening (pap smears) – The vaccine will NOT protect against all types of genital HPV – Women may not have completed the full series of vaccinations – If they had been exposed to one or more types prior to vaccination, there is still a risk for cervical abnormalities and/or genital warts to develop Women should continue to practice protective sexual behaviors since the vaccine will not prevent all cases of genital HPV or other STDs, including HIV

HPV Prevention Abstinence Monogamy Condoms Removal of warts Vaccine (Females aged 9 -26)

HPV Prevention Abstinence Monogamy Condoms Removal of warts Vaccine (Females aged 9 -26)

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