Human Papilloma Virus- 30-75% Sexually Active Infected
Poses Multi-Billion Dollar Public Health Dilemma
By Michelle Boorstein, Associated Press
From Robert Boudreau
NEW YORK (AP) - The women who test positive for the human papilloma virus at Brenda Slade's clinic always ask the same panicked questions, and every time Slade is forced to give them the same answer: We don't know.
We don't know if you can ever get rid of it.
We don't know if condoms can protect your future sex partners.
We don't know if it will give you cervical cancer.
With other sexually transmitted diseases, "you can do something to treat it and it goes away,'' says Slade, who runs the women's health clinic at Columbia University in New York City. "For HPV it's much more vague. ... It could be a lifelong condition, but we don't know. That's what creeps people out.''
In the last decade, HPV has become the country's most common sexually transmitted disease and now poses a most perplexing public health dilemma.
It is harmless to most of the millions of Americans who contract it but causes cervical cancer in a tiny percentage of female carriers. The problem is, doctors so far can't predict who will fall ill.
In the meantime, all women with HPV get the same intensive, expensive treatment: multiple doctor visits and Pap smears and, sometimes, a preventive measure - surgical removal of the lining of the cervix that can leave them sterile. All at a cost exceeding $3.5 billion a year.
"(Let's say) for every thousand people with HPV you detect, only one will get a serious outcome. So are you going to spend the money for the 999 women so that you can find out about the one woman? That's the question from a public health standpoint,'' said Dr. H. Hunter Handsfield, director of the sexually transmitted disease control program at Seattle's King County Public Health Department and a visiting scientist at the federal Centers for Disease Control and Prevention.
Research into HPV has exploded in the last five to 10 years, with the discovery that it causes almost all cases of cervical cancer " the fourth deadliest among women worldwide, behind cancers of the breast, stomach and lung.
Scientists now estimate that 30 percent to 75 percent of sexually active adult Americans, heterosexual and homosexual alike, are infected with HPV.
Based on DNA-based research, the scientists believe HPV has 60 to 80 varieties, with 15 of the strains considered likely to cause cancer.
Some strains are virtually undetectable, but even when HPV is found, traditional medical tests are not sophisticated enough to pinpoint which type, or types, of the virus a woman has or how likely she is to develop cancer.
A dozen promising new testing products developed by pharmaceutical companies have failed to win over most doctors, who remain unconvinced of their accuracy or even whether identifying an HPV variety can help the patient: Even women believed infected with the 15 suspect varieties don't always develop cancer.
"There isn't even consensus among experts on how to use the tests that are out there, what they indicate and how well they work,'' Handsfield said. "If you get a negative test, can you be assured the person isn't carrying the virus? And if the test is positive, what do you do about it?''
Some women's health advocates believe increased federal spending would boost backing for the new tests. Last year, the CDC budgeted $106 million for sexually transmitted diseases, compared with $616 million for HIV/AIDS, $139 million for breast and cervical cancer and $119 million for tuberculosis.
While more Americans die from AIDS each year than from sexually transmitted diseases, CDC officials say STDs affect many millions more people and cost huge sums to treat.
Genital contact is HPV's primary route of infection, and single younger people with multiple sexual partners are most at risk. Men with HPV typically show few ill effects, but the virus has been connected to rare cases of penile cancer. Researchers are trying to determine whether condoms offer any protection, although it's known the virus is transmitted through the skin rather than bodily fluids.
Human papilloma is a particularly virulent virus. At the University of Washington, researchers have tracked 600 young women through their college years, starting in 1991, and found that 20 percent contracted HPV after their first sexual encounter. More than 90 percent of those infected women picked up another HPV strain within two years.
Most HPV is diagnosed before it becomes cancerous, usually due to genital warts or abnormal Pap smears. Since the link to cervical cancer is so strong, doctors who find HPV routinely take a closer look at the vagina and cervix. If a biopsy shows the abnormal cells are likely to become cancerous, women are often advised to have the lining of their cervix removed, usually done with lasers or by freezing. The procedure carries a risk of infertility through damage to the cervix.
The government has approved a few new tests, but doctors have been lukewarm about using them and seem to prefer to rely on Pap smears. Although the Pap test is estimated to miss suspicious conditions in about 20 percent of cases, it is fully covered by health plans and doctors are familiar with its limits.
So far, private insurance companies reimburse the new tests sporadically, although the government on Jan. 1 began covering one test for Medicaid and Medicare patients.
Public health officials say they aren't working against the DNA-linked tests but feel their benefits are unproven.
On Thursday, the CDC issued its regular guidelines on sexually transmitted diseases, offered every four to five years. The agency said essentially the same thing it said in 1993: Doctors' treatment "decisions should not be made on the basis of HPV (DNA) tests.''

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