Wanted: A Balanced Policy And Program Response to HPV and Cervical Cancer
Genital human papillomavirus (HPV) is an extremely common sexually transmitted disease (STD) that cannot be entirely prevented through condom use. HPV also has been linked to cervical cancer. Increasingly, proponents of sexual abstinence outside of marriage are using these facts to tar the entire public health, risk-reduction approach to unplanned pregnancy and STD prevention as a myth. HPV provides prima facie medical evidence, they say, for their long-standing moral position that the only truly safe sex is that which occurs among married couples.
The issue of HPV has emerged center-stage in the context of pending federal legislation designed to help low-income, uninsured women with breast or cervical cancer obtain treatment. Specifically, Rep. Tom Coburn (R-OK), a conservative physician and long-standing opponent of government-funded family planning programs, was successful earlier this year in attaching to the Breast and Cervical Cancer Treatment Act of 1999 a variety of controversial initiatives targeting HPV. They range from taking steps toward requiring cases of HPV to be reported to the federal government to mandating that condom labels contain a cigarette-type warning that condoms do not protect against HPV and that HPV is linked to cervical cancer. Coburn also has seized this opportunity to attack the family planning community—with its ongoing call for safer-sex practices—for turning its back on the disease.
Coburn's proposals—which he also has now introduced as a freestanding bill—have provoked controversy, and not just among family planning advocates. Indeed, most public health experts agree that promoting abstinence outside of marriage as the primary, let alone only, answer to HPV and cervical cancer is an unduly simplistic approach to a complex problem.
What Is HPV?
HPV is actually a group of over 70 known strains of virus. While different strains invade different parts of the body, some 30 are sexually transmissible and are considered to constitute genital HPV. Because these strains are spread through skin-to-skin contact, not through an exchange of bodily fluids, genital HPV cannot be entirely prevented by condom use.
Approximately 5.5 million new genital HPV transmissions, representing about one-third of all new STD infections, are thought to occur each year. An estimated 20 million people—men and women—are thought to have an active HPV infection at any given time, and according to a 1997 article published in the American Journal of Medicine, nearly three out of four Americans between the ages of 15 and 49 have been infected with genital HPV at some point in their life.
Genital HPV, which is frequently asymptomatic, also is often harmless; in most cases, the body's immune system fights it off. Certain strains, however, can lead to genital warts. These warts can be treated, but because the virus typically remains in the body, symptoms may reappear. Other genital HPV strains are linked to cervical cancer in women. Indeed, approximately 10 strains are deemed "high-risk"—not because they usually, or frequently, cause cervical cancer, but because virtually all cases of cervical cancer are associated with those strains.
Cervical cancer is relatively rare in the United States, numbering only 13,000 cases per year. Moreover, cervical cancer is on the decline. Pap tests can detect cervical dysplasia—precancerous changes of the cervix—in its earliest stages, and cervical dysplasia itself is often easily treatable. In fact, since the introduction of the Pap test in the 1950s, cases of cervical cancer have decreased dramatically—74% between 1955 and 1992.
Coburn and His Critics
Coburn and organizations such as the Family Research Council charge that because condoms cannot entirely prevent HPV transmission, "safer sex" is a fallacy. As Coburn recently put it, "the only real protection against [HPV] is a lifestyle of abstinence before marriage and fidelity within marriage." Accordingly, to ensure that those who are sexually active hear the truth about their risk for HPV, Coburn would require condom labels to carry the warning that condoms cannot prevent the transmission of HPV and that HPV can lead to cervical cancer.
Leading public health experts, however, take issue with Coburn's condom-labeling proposal. Their sentiments are summed up in the statement of Rep. Henry Waxman (D-CA), a congressional leader on public health issues for over 20 years, during committee consideration of the Breast and Cervical Cancer Treatment Act. While fully agreeing that it is important for people to understand that condom use cannot entirely prevent the transmission of HPV, Waxman stressed that "we want to be sure that we do not end up with an unintended effect of confusing people about the situations when condoms do work—in HIV transmission to name only one—and actually reduce their use." Moreover, he added, condom labels that "include information on HPV can result in so much information on such a small package that it reduces the effectiveness of any information."
In addition, while public health experts do not dispute that abstinence messages play an important role in preventing the transmission of STDs, including HPV, they stress that such messages need to be part of a more comprehensive approach to STD risk reduction—one that takes into account the reality of people's lives, including their willingness to refrain from sexual activity. For young people, according to Brenda Miller, director of the District of Columbia Campaign to Prevent Teen Pregnancy, "this means encouraging and supporting those who want to delay sexual activity, while preparing them to protect themselves against STDs and unintended pregnancy once they become sexually active. And people of all ages should be aware that the more sexual partners they have, the greater their risk of contracting an STD, including HPV."
At the same time, recent data indicate that it may be misleading to imply that married people are completely safe from STDs, including HPV. According to a recent Alan Guttmacher Institute (AGI) study, a sizable proportion of American women who believe that they are in a mutually monogamous relationship—some 3.5 million—are, in fact, at risk of STDs because of their partner's involvement with other sexual partners. And because HPV can be contracted from one sexual partner and then remain dormant, it can be unknowingly transmitted years later to another sexual partner, including a spouse.
Another Coburn proposal is to establish a process to lead to the required reporting of all cases of genital HPV to the Centers for Disease Control and Prevention (CDC). According to Coburn, such a measure would provide a more accurate picture of the prevalence of HPV, including information on the age-groups and populations particularly affected by the disease. Once again, however, public health experts question the wisdom of reporting the millions of cases of HPV—both because tests for HPV, which are currently expensive and not widely available, cannot yet determine which cases will lead to cervical cancer and because cervical cancer is so rare. When asked to comment on such a reporting requirement, Helene Gayle, director of the National Center for HIV, Sexually Transmitted Diseases and Tuberculosis Prevention at CDC, responded, "We don't have a good way to determine which of the women found to be positive for HPV will go on to develop cervical cancer. [Reporting HPV is] a very inefficient way to look for the real problem, which is cervical cancer." Gayle asserts that "the best way to screen for cervical cancer is a Pap smear, not to test for HPV."
Indeed, guidelines promulgated by the American College of Obstetricians and Gynecologists (ACOG), the American Cancer Society and the National Cancer Institute recommend that sexually active women and women who have reached age 18 should have an annual Pap test and pelvic examination. And according to Marsha Simon, director of government relations at ACOG, "since cervical cancer presents the greatest threat to low-income women who face barriers to obtaining access to Pap tests and other reproductive health care, every effort should be made to engage the public health community in helping women to obtain access to Pap smears, regardless of their income level or insurance status."
Clinics: Problem or Solution?
In promoting his HPV initiatives, Coburn charges that organizations such as publicly subsidized family planning clinics—and federal agencies, such as CDC, that advocate condom use as a means to prevent STD transmission—are ignoring the truth about HPV and providing misleading information that puts lives at risk. An October editorial in the Daily Oklahoman quotes Coburn as saying, "Planned Parenthood has been part of the cover-up of one of the greatest threats ever posed to women's health. They don't want to talk about HPV."
However, Sylvia Clark, president and chief executive officer of Planned Parenthood of the Rocky Mountains, counters Coburn's assertion, stressing the key role that government-subsidized family planning clinics play in educating people about STDs, including HPV. "We are one of the few places where people can get full, honest, legitimate information about their risk for contracting HPV," she says. "We educate people in a confidential, safe environment on how to limit and restrict their risks, including their risk of reinfection. We help them to assess their risks, in terms of their own behaviors and that of their partners, so they can choose healthy lifestyles and figure out how best to minimize their risks. That may include getting themselves out of risky relationships. We also teach them to be meticulous about both male and female condom use" so that they can better protect themselves against STDs, including HIV, as well as unintended pregnancy.
Clark notes that as a major provider of reproductive health care for low-income women and teenagers who are often uninsured or lack another source of care, family planning clinics today serve a significant proportion of women in need of Pap smears and testing and treatment for STDs. In fact, according to AGI estimates, the 7,000 publicly funded family planning clinics in this country provide Pap smears and pelvic examinations to approximately one in six women of reproductive age, as well as one in three STD testing or treatment visits and one in four HIV tests to American women.
Clark adds that clinics not only are providing these services but "some clinics are also engaged in research to help identify strains of HPV, including those linked to cervical cancer." She continues: "Ironically, at a time when opponents of subsidized family planning programs attack the clinic system for turning its back on HPV, clinics are not part of the problem but part of the solution. These are the very places we should be putting our resources in the fight against cervical cancer and STDs."