Women who screen positive for HPV: Addressing the STI stigma

Human Papilloma Virus is a common double stranded DNA virus affecting both men and women. There are over 100 different types of HPV, of which 40 types of HPV will affect the ano-genital region. Although the virus is “transmitted sexually” through direct genital contact and sexual relations it has not been viewed as a traditional STI. HPV establishes productive infection in keratinocytes only (skin and mucous membranes) and is largely asymptomatic. Eight out of 10 sexually active women will come into contact with the virus at some stage in their lives; with most being unaware they have been affected as the virus is usually temporary. An individual’s cellular immunity usually allows for the virus to be cleared spontaneously and thus has little long term significance. There is currently no treatment for HPV infection, although its consequences may be managed.

Testing for HPV involves examining the genetic material extracted from the cells obtained during routine cervical cytology specimens. In October 2008, the NHS Cervical Screening Programme introduced liquid based cytology (LBC) sampling. This implementation significantly improved the accuracy of sampling and provided the simultaneous opportunity to test for HPV and thus women would not have to undergo additional invasive testing. HPV testing was incorporated into NHS Cervical Screening Programme in April 2011 after a successful pilot programme. 

HPV testing has been shown to be a more accurate screening tool than cytology alone, with the sensitivity of HPV testing being 95%, and thus better than cytology at detecting high grade CIN or CGIN at colposcopy. However, HPV testing has been shown to have a low specificity, due to the infection often only being present temporarily. For example, a large number of women may test positive but will not have significant cytological abnormalities as the test can pick up transient infection.1 A positive HPV test indicates infection with a high risk HPV subtype (e.g 16, 18, 31, 33, 39, 45, 51, 52, 56, 58, 59, 66, 68, 73) that is linked to cervical cancer. 

Laboratory diagnosis of HPV positivity can lead to significant psychological distress in the woman, even after a careful, factual and sympathetic explanation of HPV and sexual transmission. In the majority of cases, HPV infection will have been confirmed at the same time as an abnormal smear result is received thus reinforcing that cervical cancer is caused by a sexually transmitted virus.

The NHS cervical Screening Programme aims to utilise HPV testing to triage cytology referrals to colposcopy. HPV testing can help distinguish between women who have an increased risk of having high grade cytology from those women who have a lower risk. A further development for the UK cervical screening programme is the introduction of “HPV test of cure”.  This aims to test for HPV in women following treatment for CIN. 

The disadvantage of HPV testing is that in the majority of women HPV infections can spontaneously resolve within one to two years and may not have health implications. 

 

Is HPV a true STI?

HPV infections occur in the 15 to 25 year age group and spontaneous regression is common. However, a positive diagnosis carries with it the stigma of a STI and many young people will focus on the embarrassment of HPV positive test result and the subsequent difficulties that comes with confronting a partner.2 Partners usually share HPV. A study has shown that there is minimal difference between male to female (3.5 per 100, 95% CI 2.7-4.5) and female to male (4 per 100, 95% CI 3-5.5) transmission rates. Transmission was also found to be similar across HPV subtypes and oncogenic risk categories.3 

HPV infection has been shown to be highest after the onset of sexual activity. If the first episode of sexual intercourse occurs within one year of menarche, there is a significant increased risk of cervical cancer. This is possibly due to the exposure to HPV occurring at a time of rapid changes to the cervix at a cellular level or due to behavioural patterns that may include multiple sexual partners and thus exposure to multiple subtypes of HPV (including 16 and 18).

In many populations a second peak occurs in 45 to 50 year olds. The question that is raised is this late peak due to re-activation of a prior infection or due to a new infection acquired through sexual activity with a new partner.4 A study has shown that natural immunity does not play a role in controlling the extent of re-infection with a different type of HPV indicated by the fact that initial infection rates were lower than those of re-infection with a different type. 

 

The role of condoms in the prevention of HPV

Condoms may lower the chances of transmission, but need to be used with every type of sexual act and for the entire duration. However, it should be noted that HPV can infect areas not covered by a condom. Winer et al found that 9.7% of women who reported sexual contact not involving intercourse tested positive for HPV DNA.5 A further study by Manhart et al illustrated that it is not possible to make an exact estimation of condom protection against HPV (range 0% to 80%).6 The same study found that although condoms may not prevent HPV infection, condom use may lower the risk of genital warts, high grade dysplasia and invasive cervical cancer. The study concluded that it is unlikely that condoms offer the same level of protection against genital HPV as they do against HIV and other sexually transmitted infections. Winer at al showed that consistent use of condoms for more than 50% of sexual acts significantly reduced the risk of cervical and vulvavaginal HPV infection by 50% compared to partners who used condoms 5% of the time (95% CI 0.3-0.9).5 

Condom use in HPV positive women may help with CIN regression because the cervix is not repeatedly being exposed to a HPV positive partner.7 Davis et al found condoms could offer 87% protection against HPV.8

Condom use can promote the regression of HPV related lesions in men whose partners are found to have CIN. Bleeker et al found the median time for regression of flat penile lesions was 7.4 months for condom users versus 13.9 months for non-condom users (95% CI, 1.2-3.7).9 The HPV vaccine is currently only available for women and does not protect against all types of HPV. 

It should still be kept in mind that people with only one lifetime sex partner can still get HPV. The only sure way to prevent HPV infection is abstinence.  

 

Psychosocial aspects

McCaffery et al showed that an HPV positive status can impose a psychosocial burden on women above and beyond the impact of an abnormal smear.10 However, Kitchener et al 2009 concluded that HPV testing does not add significant psychological distress when combined with cytology in routine screening. 

The emotional responses to a HPV positive result can include depression, anxiety, anger, compulsion and obsessions. McCaffery et al looked at social dysfunction and HPV, with 25% of the positive diagnosis group affected vs. only 7.9% of the HPV negative group.11 Additionally, 17.9% HPV positive women reported severe depression vs. 10.5% HPV negative women.

As HPV is sexually transmitted, women are often concerned about passing the infection to future partners or that they may have infected previous partners. Anxiety also centres around disclosing their HPV positive status to their partner, family or friends. There is also anxiety concerning the cancer risk associated with HPV infection and further concerns about investigation, treatment and fertility.  

The response to a HPV positive status may also be influenced by how healthy a relationship is. For example a HPV positive result in a troubled relationship may raise issues about trust, fidelity and blame for the infection.11 In order to cope with HPV positive result a woman may chose not tell her partner about this and instead focus on dealing with the abnormal smear result. Some women further justify not telling their partners because they do not believe it will have impact on them and condoms do not necessarily prevent transmission. The anxiety of disclosure can be made worse by the lack of education about HPV among partners, family and friends.11 Wilkinson et al 1999 found that the associated anxiety can be addressed by better informing patients, which could take place in the GP setting or gynaecology clinics.

Furthermore, McCaffery et al showed that culture and religion also have an impact on the response of a HPV positive result.11 Young Asian women may conceal the fact that they are sexually active and will thus tend to hide the fact that they have gone for cervical screening as it is implies sexual activity. This group of young women will tend to rely on support from friends, sisters and partners rather than their parents. However, even in African Caribbean and white British women who are traditionally considered more open about discussing cervical screening results had significant concerns about disclosing their HPV positive status to their supporters.

 

Psychosexual aspects

Receiving the diagnosis of any STI, including HPV can have a significant impact on a woman’s sexuality. Conaglen et al found the psychosexual impact to be similar to patients who had been diagnosed with the Herpes Simplex virus.12 There can be a stigma attached to the infection with connotations of promiscuity, which is degrading and can make a woman feel ashamed, dirty and inadequate.1 Such feelings can result in a loss of sexual desire, difficulty with arousal, less frequent intercourse and dyspareunia.

HPV infection also raises issues about the health of the partner and commitment to the relationship, which, in turn, can affect sexual function. McCaffery et al showed that HPV positive women demonstrated significant concerns about their feelings towards a sexual partner and their sexual relationship in comparison to women who tested HPV negative.10 In those infected with HPV subtype six and 11, the presence of genital warts will results in cosmetic concern, which may result in rejection by partner. Furthermore, it was shown that one third of HPV-positive women felt significantly worse about past and future sexual relationships in comparison to 2% of HPV negative women.  

The likelihood of a psychosexual disorder increases with increased reoccurrences of HPV infection.1 The methods used to treat physically apparent HPV e.g genital warts (physical-chemical therapy, diathermocoagulation, laser therapy or Imiquimod) can be long and painful and result in vulvodynia and dyspareunia. Clinical experience has also shown that women with a satisfying sexuality before the HPV diagnosis are those less affected by genital warts and their cervical treatment. The psychosexual issues may need to be addressed by individual or couple counselling.

 

The future: educating Women on HPV

Anhang et al showed that women lacked basic knowledge about HPV testing, abnormal results and follow up procedures.2 The study showed that physicians were not routinely informing, and thus educating, women about HPV testing, cervical cancer and the risk factors associated with contracting HPV. Cermak et al found that younger doctors were more likely to discuss these topics than their older colleagues.13 Younger women were more open when discussing these topics with their doctors than married older women.

It is the responsibility of health care workers to counsel women accurately about the implications of a HPV positive result. GP consultations, gynaecology out-patients and secondary school health programs can all provide opportunities to educate women. This should include a discussion about different strains, information about transmission, prevention, treatment and the relationship with cervical cancer. Where possible a more individual assessment should also be made taking into account the woman’s age and risk, and the fact that complying with screening programme reduces the risk significantly. 

In summary, the inclusion of HPV testing within the NHS Cervical Screening Programme is a major change that will only benefit women. However, it is important that any results are given sensitively, with careful attention paid to the women’s beliefs about HPV as this will ultimately assist in improving patient education and understanding, and thus help to reduce the psychological burden that HPV currently has the potential to cause.


References


  1. Graziottin A,  Serafini A. HPV infection in women: Psycosexual impact of genital warts and intraepithelial lesions. The Journal of Sexual Medicine 2009; 6(3): 633-645.
  2. Anhang R, Wright TC, Smock L, Goldie SJ. Women’s Desired information about Human Papillomavirus. Cancer 2004; 100(2):315-320.
  3. Burchell AN, Coutlee F, Tellier PP, Hanley J, Franco EL. Genital transmission of human papillomavirus in recently formed heterosexual couples. Journal of Infectious Diseases 2011; 204(11): 1723-1729.
  4. Trottier H, Ferreira S, Thomann P, Costa MC et al. Human Papillomavirus Infection and Reinfection in Adult women:the role of Sexual Activity and Natural Immunity.  Cancer Research 2010; 70: 8569-8577.
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  6. Manhart LE, Koutsky LA. Do condoms prevent genital HPV infection, external genital warts, or cervical neoplasia? A metanalysis. Sexually Transmitted Diseases 2002; 29: 725-735.
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  9. Bleeker M, Hogewoning C, Voorhort F, Van Den Brule A, Snuders P, Starink T et al. Condom use promotes regression of human papillomavirus associated penile lesions in male sexual partners of women with cervical intraepithelial neoplasia. International Journal of Cancer 2003; 107: 804-810.
  10. McCaffey K, Waller J, Forrest S, Cadman L, Szarewski A, Wardle J. Testing positive for human papillomavirus in routine cervical screening: examination of psychosocial impact. BJOG 2004; 111:1437-1443.
  11. McCaffery K, Waller J, Narzroo J, Wardle J. The Social and Psychological impact of HPV testing in cervical screening: a qualitative study. Sex Transm Infect 2006; 82: 169-174.
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