Human Papilloma Virus or HPV

Genital human papillomavirus (HPV) infection is one of the most common sexually transmitted infections (STIs) which affects both men and women.There are more than 100 types of HPV, of which at least 13 are cancer-causing (also known as high risk type).Types 6 and 11 are responsible for up to 90% of anogenital warts. Types 16 and 18 are associated with approximately 70% of cervical cancers, and are also associated with cancers of the vulva, vagina, penis, and anus.1HPV is largely transmitted through sexual or close intimate contact, with an estimated 75% of sexually active people affected with at least one HPV infection at some point in their life.2 The majority (70% to 90%) of those infected do not have symptoms and spontaneously clear the infection, usually within two years. However, if these cells persist and infect the cervix area abnormal pre-cancerous cells may develop which, if undetected may progress to invasive cervical cancer.3Vaccinations can protect against some types of HPV which cause cancer, however, there are limitations with the vaccinations and they do not eliminate the need for regular HPV and/or cervical screening throughout life.

Contracting HPV and genital warts

Anyone who is sexually active can get HPV, even if you have had sex with only one person. You also can develop symptoms years after you have sex with someone who is infected making it hard to know when you first became infected.Using latex condoms the right way every time you have sex can lower your chances of getting HPV, but HPV can infect areas that are not covered by a condom – so condoms may not give full protection against HPV.

HPV and the risk of developing cervical cancer

Women with a persistent infection with a high-risk HPV type are at risk of cervical cancer. In some instances, persistent infection with the high-risk types of HPV may ultimately progress to invasive cancer if not detected and treated. This usually takes 10 years or more. Persistent HPV infection is always an underlying cause of cervical cancer. However, among women with persistent HPV infection, additional factors that may contribute to the development of cervical cancer include smoking, taking hormonal contraceptives, having a suppressed immune system, for instance as a result of HIV infection, and the presence of other sexually transmitted infections.4In Aotearoa New Zealand, the most important risk factor for developing cervical cancer is never having a smear or not having cervical smear tests regularly. Having a smear test every three years is the best way to detect changes to the cells of the cervix that may later lead to cancer. Screening New Zealand states having regular cervical smears can reduce the risk of developing cancer by about 90 percent.

HPV vaccine

Vaccination can protect against infection with the HPV types covered by the vaccine, provided the woman is not already infected with those types of HPV. However, vaccination does not protect against all HPV types and a woman may still become infected with another HPV type not included in the vaccine. HPV vaccines are not a treatment for HPV infections.There are two types of HPV vaccines licensed for use in Aotearoa New Zealand. The Gardasil® vaccine is publically funded and is currently offered to girls aged between 12 years and up to their 20th birthday through the National Immunisation programme. The vaccine is given in three doses, usually an initial dose with follow-ups two months and six months afterwards.It is not currently funded for boys. Women and men outside the eligible publically funded age range may choose to purchase this vaccine privately at a cost of about $450 – $500.Gardasil® is said to be effective in protecting against infection with the HPV types 16 and 18 and also the two common types of low-risk HPV (types 6 and 11) that cause up to 90% of genital warts but do not cause cervical cancer.The other HPV vaccine licensed for use in Aotearoa New Zealand is Cervarix® which is effective in protecting against infection with HPV types 16 and 18. Cervarix® is not publicly funded in New Zealand. More about the vaccine can be found at http://www.cervicalcancervaccine.govt.nz/The World Health Organisation (WHO) have concluded that the use of quadrivalent HPV vaccine (Gardasil) significantly decreases the incidence of anogenital warts. There is also evidence of a reduction in high-grade cervical abnormalities and reduction of precancerous cervical lesions among young adult women. However, because of the length of time from persistent HPV infection until the development of invasive cancer, studies are ongoing and definitive conclusions about the vaccines impact long-term on rates of cervical cancer cannot yet be drawn.In terms of safety, the WHO Global Advisory Committee for Vaccine Safety (GACVS) has regularly reviewed the evidence on the safety of HPV vaccines including post-licensure surveillance data from the United States, Australia, Japan and the manufacturers. Data from all sources continue to be positive regarding the safety of both vaccines. The Committee concluded in March 2014 that both HPV vaccines continue to have an excellent safety profile .However adverse reactions following the administration of Gardasil have been reported. If you think you have experienced an adverse reaction make sure you report this to your doctor or nurse. Alternatively you can report directly to the Centre for Adverse Reactions Monitoring (CARM) at the New Zealand Pharmacovigilence Centre.

New Vaccines

To increase the protection conferred by HPV vaccines, a vaccine has been developed in which the number of HPV types targeted is increased to 9. It is currently under regulatory assessment for possible marketing authorisation. We will provide more information on this new vaccine when it is available.

HPV Vaccine controversy

Some questions about HPV and HPV vaccines and testing

The introduction of HPV vaccines around the world has not been without controversy. While the vaccine was heralded as a major development in the fight against cervical cancer by some women’s health and public health clinicians and advocates, the vaccine has had its opponents as well as those who have advised caution.Some have opposed the vaccine on the basis of moral concerns, arguing that vaccinating pubertal children against a sexually transmitted infection will result in the erosion of ‘family values’ and a possible increase in sexual activity prior to marriage.Some have raised concerns about safety aspects of the vaccine and its effects particularly on young girls. Importantly, if fewer women have smears, erroneously thinking they are safe, there is a possibility that immunisation could lead to an increase in cervical cancer cases.Women’s Health Action, while welcoming the opportunity to reduce the incidence of cervical cancer, also advise caution. In particular the potential impact of the vaccination programme on cervical screening uptake must be evaluated along with any unanswered questions about its safety and long-term effectiveness. There is still a lack of understanding about HPV and its relationship to cervical cancer in the population and we need more education to ensure young women and their families can make informed decisions about cervical cancer prevention.6Women’s Health Action believes the vaccine should also be targeted to boys and men as HPV is transmitted by, and affects, all sexes. Girls and young women should not be held solely responsible for preventing sexually transmitted infections. Both young men and young women should be involved in education programmes about HPV disease and their role in preventing HPV and other sexually transmitted infections through safe sex.

Preventing Cervical Cancer: an integrated approach

HPV vaccines provide a promising new tool in helping to address the global burden of HPV-related diseases including cervical cancer. However, the WHO recommends that the prevention of cervical cancer and other HPV diseases will be best achieved through a coordinated and comprehensive strategy to tackle these diseases. This strategy should include education about reducing behaviours that increase the risk of acquiring HPV infection (safer sex); information to women about screening, diagnosis and treatment of precancerous lesions and cancer; and access to quality screening and treatment services. The WHO also recommends that opportunities to link the introduction of HPV vaccine to other programmes targeting young people should be sought (e.g. through adolescent health services).7

HPV testing

HPV testing provides an accurate way of telling if a high-risk type of HPV is present in a woman’s cervix. It helps to determine those women who need further assessment and those who don’t.The HPV test is usually done at the same time as the cervical smear test using some of the same sample of cells. The HPV test detects whether HPV genetic material (DNA) from any of the types of HPV most commonly associated with cervical cancer is present.A positive HPV test means a woman has high-risk HPV and should be monitored to see that the infection goes away and that she does not develop abnormal cells. It does not mean that a woman has cancer, but it does mean that it is important she has follow-up appointments so any cell changes can be found and treated early.There is currently no approved HPV test for men.It is important to note HPV vaccination is a primary prevention tool and does not eliminate the need for screening throughout life, since the vaccines do not protect against all high-risk HPV types.

Cervical screening

Whether women choose to be immunised against HPV or not, they will still need to participate in regular cervical screening. See more on the Cervical Screening Health Topic. 

  • References

    1. World Health Organisation, ‘Human papillomavirus vaccines: WHO position paper, October 2014’, Weekly epidemiological record No. 43, 2014, 89, 465–492. http://www.who.int/wer/2014/wer8943.pdf?ua=12. Parker, Christy. “One for the girls? “Cervical cancer prevention and the introduction of the HPV vaccine in Aotearoa New Zealand.” Women’s Studies Journal 24 (2010): 25-39.3. Australia and New Zealand HPV Project. (2010). A Patient Guide: HPV (wart virus) in perspective. Auckland, New Zealand: Author.4. Parker, Christy. “One for the girls? Cervical cancer prevention and the introduction of the HPV vaccine in Aotearoa New Zealand.” Women’s Studies Journal 24 (2010): 25-39.5. World Health Organisation, ‘Human papillomavirus vaccines: WHO position paper, October 2014’, Weekly epidemiological record No. 43, 2014, 89, 465–492. http://www.who.int/wer/2014/wer8943.pdf?ua=16. Australia and New Zealand HPV Project. (2010). A Patient Guide: HPV (wart virus) in perspective. Auckland, New Zealand: Author.7. World Health Organisation, ‘Human papillomavirus vaccines: WHO position paper, October 2014’, Weekly epidemiological record No. 43, 2014, 89, 465–492. http://www.who.int/wer/2014/wer8943.pdf?ua=1