Health -- HPV

Washington Post Health writer Laura Sessions Stepp and Dr. Monique Powell Davis of Howard University Hospital take your questions and comments about Stepp's story on what young people think about HPV and how it affects their sex lives.

Stepp and Davis were online Tuesday, April 3, at 2 p.m. ET.

A transcript follows.

____________________

Laura Sessions Stepp: Welcome to our live chat about the HPV virus and the vaccine that will guard against four strains of the virus, including two that cause cervical cancer. The Centers for Disease Control recommends that females 9-26 get the vaccine. Their recommendation has been met with acceptance, opposition and considerable confusion. We have with us today two physicians ready to answer your questions: Dr. Monique Powell Davis and Dr. Genea Lawrence, both from Howard University Hospital. I also will speak to questions relating to my story in today's Washington Post. First, I'm going to pose two questions to the docs and then we'll get to your questions.

_______________________

Laura Sessions Stepp: Dear Docs,

I have two questions I'd like you to answer before we get to the readers:

1) What are the misconceptions surrounding HPV and the vaccine that you encounter most frequently?

2) Dr. Davis, as a parent of young women, what do you think about giving the vaccine to girls?

_______________________

Washington, D.C.: I found your article enlightening, particularly as I wasn't aware that sexually active adults were getting the shot, considering the cost involved and the fact that it is touted as rather useless if you are sexually active.

That being said, while I can see the concern towards a blase attitude towards possibly cancer causing diseases, don't you find it at all refreshing that young adults are more concerned about other pressing matters? It seems to me that young adult sexuality is an issue because we make it an issue. Teenagers and college age kids learn best when items are presented to them with common sense and most importantly without sensationalism. I think most of them look on bemused while the adults wring our hands over articles where guys and girls who stop using condoms because of birth control. If they are tested, monogamous and using birth control, aren't they doing as good as we can expect?

Laura Sessions Stepp: Hello chatters: We're going to go ahead with some of your questions while the doctors consider their answers.

In response to this questioner, in an ideal world you might be correct. But many young people, especially in college, are not monogamous, do not get tested regularly and do not always use condoms.

_______________________

Dr. Monique Powell Davis: In no particular order:

First...that if you already have HPV you shouldn't get the vaccine.

Second...that you are no longer eligible for the vaccine after you are 26 years old.

Third...that getting the vaccine causes women to be more promiscuous.

_______________________

New York, N.Y.: I read the article, and I'm still stumped about why anyone WOULDN'T get this vaccine. Even if you're not that sexually active -- you get a tetanus shot even if you don't make it a habit of stepping on rusty nails, don't you? What's the possible downside of the vaccine besides a 5-second pinch from the needle? Should we eliminate all childhood vaccines because it's so rare that anyone catches rubella these days?

Laura Sessions Stepp: Interesting point. Some people are concerned that the vaccine hasn't been tested enough, that we don't yet know about possible longterm effects of it. However, scientists I've interviewed who do not work for the drug companies say it is one of the safest vaccines out there.

_______________________

Washington, D.C.: I am a 26-year-old woman with a pretty limited sexual history. I would like to get the vaccine, but I'm afraid it will be denied to me because I turn 27 late this summer. How strict is the younger than 26 rule?

Dr. Monique Powell Davis: the vaccine is FDA approved for ages 9-26, but there is no rule preventing you from getting the vaccine.

_______________________

St. Mary's City, Md.: I was very concerned when a Center for Disease Control adviser (Dr. Reginald Finger) opposed even making the HPV vaccine available because it might discourage abstinence. Beyond the immorality of exposing girls to the risk of cancer just to scare them away from sex, your article seems to imply that Finger is incorrect about the vaccine's possible social effect. Am I reading your article correctly?

Laura Sessions Stepp: Yes, according to the best experts I could find, there is no solid evidence at this time that a vaccine will change sexual behavior.

_______________________

Chicago: I was diagnosed with HPV about three years ago. I told my boyfriend at the time who responded, "yeah, my ex- had that too." He was a carrier and didn't even know it. Men really don't have a clue about this stuff.

I just wanted to tell all the women who can still get it to be vaccinated. HPV has meant a trip to the OBGYN every 4 months for me, constant abnormal paps, and having colposcopies -- a small chunk of my uterus cut out -- once a year. It's painful, it's a pain to constantly be going to the doctor, and I wish it had never happened.

Laura Sessions Stepp: Thank you for sharing your story.

_______________________

Washington, D.C.: I was diagnosed with HPV about ten years ago at the age of 26. It was discovered through a pap smear, was subsequently treated and hasn't recurred. Since this vaccine has become big news, it has made me very angry to read ignorant comments that only promiscuous women contract this STD, and that the vaccine will encourage promiscuity. I contracted it from the first man I had sex with (yes, at age 26). I had never heard of HPV before I was diagnosed. HPV is a real health issue that needs to be taken seriously, and people shouldn't allow ignorance or fear to prevent women from taking advantage of a preventative measure.

Laura Sessions Stepp: Thank you for that story. Hopefully the controversy surrounding the vaccine and stories like yours will at least combat the ignorance problem.

_______________________

Chicago : Laura,

How did you find the students to interview for your story? Most of them seemed tragically ignorant about sexual health.

Laura Sessions Stepp: In some cases, I went through university officials and in other cases, contacted students I knew and asked them for other students. Actually, most were no more ignorant than older adults I've talked to recently.

_______________________

Dr. Monique Powell Davis: As a mother of young girls, I feel it's important to protect my children from cervical and vulvar cancer, as well as genital warts, the HPV vaccine affords me an opportunity to do that.

_______________________

Portland, Maine: The fact that the HPV vaccine is protecting against only four strains of HPV (two that can lead to genital warts and two responsible for about 70 percent of cervical cancers) appears to be unimportant in the media. It seems possible that females being inoculated will have a false sense of security that they are completely safe from the virus and cervical cancer. What is being done, or should be done, to ensure that young women aren't endangered by a sense of complacency?

Laura Sessions Stepp: That's an excellent question. Campus health officials, and knowledgeable medical authorities, are responsible for telling their patients exactly what the vaccine covers and doesn't cover. The problem is, human beings don't always act on what they know. For example, studies show that college students use condoms during intercourse only about half the time. This despite the fact that most of them know why condom use is important and can get free condoms on campus.

_______________________

New York, N.Y.: For the first poster: no, if young people are using condoms, that's NOT the best they can do. I am 30 years old and have always used condoms. And I have HPV. I get a mandatory Pap smear every six months because of pre-cancerous cells that my ob/gyn needs to monitor. I usually have to have a colposcopy, and sometimes a biopsy. And again -- I've always used condoms.

It's a shot. It's one shot. I'd do anything to be younger than 26 and able to have this vaccine, and it's a slap in the face to read about these women who aren't taking advantage of something that could save their lives, no matter how careful they think they're being.

Laura Sessions Stepp: Thank you for your response.

_______________________

Detroit: What is the earliest age a girl can receive the vaccine?

Also, why are males not receiving the vaccine? It seems this would help prevent the spread of the virus.

Laura Sessions Stepp: The Centers for Disease Control recommends the vaccine for females 9 to 26. A male vaccine is under development in several labs around the country and expected to come on the market in about a year.

_______________________

Arlington, Va.: As a 24-year-old young professional, I am finding a different situation among my age group regarding the HPV vaccine. I have talked to my doctor many times about getting the vaccine, only to be told that my HMO will not cover the cost yet and I'm not a good candidate based on my age. Many of my friends have had the same experience with their doctors. One friend even had her doctor tell her that the vaccine wouldn't do anything for her since she was already sexually active and the long-term side effects are unknown, therefore it could be risky. And these are female doctors! It seems that we shouldn't be discouraged from getting the vaccine just because we are past our teenage years. Aren't we still at risk?

Dr. Monique Powell Davis: The FDA recommendation is for ages 9-26. That age grouping is based on the studied population. MERCK is currently studying the efficacy of the vaccine in older age groups. You are 24 and if you are interested in the vaccine you are still within the guidelines of the FDA approval. Your insurance may cover it, if not, you can still pay out-of-pocket.

_______________________

Silver Spring, Md.: I'm a 19-year-old sophomore at UMCP, and am currently not sexually active. I went to my OB/GYN this past January, and she recommended I get vaccinated. She gave me some informational brochures, but since they were published by the vaccine maker, they didn't give me a good sense of what the possible side effects are. I'm wary of getting such a newly-developed vaccine, so my question is, at this point, do the benefits of the vaccine outweigh the potential unknowns?

PS. Professor Carl Stepp is great!

Laura Sessions Stepp: That's a good question to research. I would suggest going to two sites. The first is the American Cancer Society, which has some very clear information on the potential risks vs. benefits. Also check out the Centers for Disease Control site (www.cdc.gov/std/hpv.htm

To other readers - Professor Stepp is my husband and I agree with her assessment.

_______________________

Philadelphia: I'm extremely bothered by all this talk about mandating that sixth-grade girls have the HPV vaccine -- but apparently not for the reasons anyone else is. If it were up to me, I would mandate that the vaccine is given to all children with their other vaccines when they enter school in kindergarten or first grade.

Moving the vaccination to occur with the majority of vaccinations makes it easier for the parents to arrange. It also takes it out of the fallacious realm of "this vaccine gives kids permission to have sex" and moves it into the more proper realm of "this is a public health issue that affects everyone."

Finally, please note that I would give it to all children. I find this whole thing about giving the vaccine only to girls to be hideous and prejudicial -- as if no boys ever get it and girls spread it only among themselves. Males can get diseases caused by HPV as well, including such lovely problems as anal cancer.

By proposing to treat only half of the population that carries the virus, we severely circumscribe the beneficial effects of giving the vaccine. If we proposed giving the polio vaccine only to women, there would be a huge outcry, and I'm stunned that no-one else seems to be making this argument.

Are there any politicians or municipalities that are making this argument, or am I apparently the only person who feels this way?

Dr. Monique Powell Davis: I concur with your perspective. There are benefits to both males and females. I would vaccinate boys also. The FDA has not approved it for boys at this time. But studies are ongoing.

_______________________

Silver Spring, Md.: I think the most disturbing comments in your article were regarding the women who seemed to cave to not using condoms if the guy didn't want to or would back off if the guy talked about trusting them, etc.

In my good group of friends from college, about eight of us, there were a couple of women that would "fall" for that kind of talk and not protect themselves like they otherwise would want to, and the rest of us would always strongly encourage them to stand up for themselves and we never had sex without condoms, and if the guy didn't like it we didn't have sex with them.

It's been about six years since I graduated and I hoped that this attitude of women backing down from using condoms when they wanted to would change. The interesting thing to me is that now these same friends that didn't use condoms are the same women that are skeptical about getting the HPV vaccine, don't take care of their finances, etc.

The rest of are more aware and pay more attention to those issues. To me, the most important thing is education on how women need to take care of themselves in all aspects of their lives, and I don't know exactly what this would take, as all my friends had relatively similar educations and learning experiences but some obviously choose to act differently.

Laura Sessions Stepp: A great addition to this conversation.

_______________________

Falls Church, Va.: There is a lot of talk about Gardisil and HPV vaccines for younger women; however, as a thirty-five year old single female, I feel a large segment of the single population has been left out of the equation.

The information being provided is always geared toward the child or younger female. I have always been cautious and am STD free. That doesn't mean that I cannot get HPV and resent a lot of the information that somehow suggests that by my age, a woman would have been exposed or is a lost cause; therefore, the vaccine isn't right for her.

What is the right course of action for those of us who are still sexually active, single, but not a child or twentysomething?

Thank you.

Dr. Monique Powell Davis: Your concerns are valid. If you wish to get vaccinated be prepared to pay out-of-pocket. Your ob/gyn is the appropriate person to ask.

_______________________

Anonymous: As a 36-year-old single woman who has always been adamant about testing and protection (against STDs as well as pregnancy), I am dismayed by the cavalier attitude held by so many people. I have 2 questions: I know HPV/cervical cancer is detected by a Pap smear, and I never miss my annual; but is there any way to protect myself from getting it from a man who might be a carrier, since there are no tests for men as of yet?

Secondly, why is it that so many women are afraid of a man's reaction if she insists he show her a clean bill of health before having sex? If he's a jerk about it or won't do it, isn't that enough to show this isn't a person a self-respecting girl or woman would want to be with?

Laura Sessions Stepp: Asking the guy to prove he is clean is the best protection there is, as far as I know. Short of that, the condom is the only other protection I know of since the virus is spread skin to skin.

_______________________

Bangor, Maine: Hi. My daughter (20) was diagnosed with HPV last year. A college nurse has told her that HPV can just "go away" at some point and she will be free of it. I don't think that's true, yet I am not sure of the facts myself and find the literature confusing. Can you please speak to this question? Thank you so very much.

Dr. Monique Powell Davis: HPV is extremely contagious and very easily acquired. In many cases the virus is cleared before it has the opportunity to cause precancerous changes in your cervix. However, you can be reinfected. The HPV vaccine affords you an opportunity to prevent infection and thereby reduce the risk of cervical cancer.

_______________________

Akron, Ohio: I was diagnosed with HPV about 25 years ago, when I was in my 20s. I was treated for it, though I do not remember what the treatments were, exactly. I remember having some kind of substance put on the genital warts. They have never returned, and I have not, to my knowledge, had a recurrence of HPV.

Can HPV simply disappear from a person's system? Does it depend on the particular strain of HPV?

Laura Sessions Stepp: Yes, it can disappear. It can also disappear and then years later, reappear (or a new one can appear.) It is apparently a very mysterious virus -- and don't forget, there are 100 strains of it. That's why the American Cancer Society and docs say women should be religious about getting their Paps -- and always informing their doctor about their previous occurrences.

_______________________

Bethesda, Md.: Thank you for taking my questions. Firstly, for women who are abstaining from sex until marriage, is the vaccine still something they should get? Also, I know the second dose is administered two months after the first one, but how stringent is that window of time? Would getting the second dose a few days prior to the two month mark have any effect on the vaccine's efficacy?

Dr. Monique Powell Davis: Yes. You should consider getting the vaccine.

There is some flexibility in the dosing schedule. Your doctor can work with you on arranging the doses so that the vaccine is still effective.

_______________________

Concerned Mom: I have two daughters, ages 19 and 22, neither of which are sexually active. That's not to say they have NOT had sex, they HAVE but currently are not in relationships where sex is happening regularly. (Yes I know this, we're pretty close). When I inquired about the HPV vaccine, their GYN sent information to them because of the way the vaccine is administered (shots given over several months) and because it's new (or so it seems), and neither of my daughter's feel they need it.

I wonder if the negative effects that "MAY" come from getting the vaccine is a deterrent to many young women.

Your thoughts?

Laura Sessions Stepp: I am impressed that you know this much about your daughters. From everything I've read, the side effects are minimal, if anything at all. As one of our early participants noted, young people don't complain about other vaccines they've gotten. Why this one?

_______________________

Fairfax, Va.: I'm a father of several young children, including a baby girl. Any parent who pushes their girl to get the HPV shot has failed as a parent. While kids are kids and will make their own bad choices, giving shots to children for a totally preventable disease based on immoral behavior is akin to throwing ones hands up and saying "I give up." Have we as a society so given up on notions of chastity and morality that the best we can do for our children is foist a shot on them and say "have at it"?

While I may fail, we parents need to teach, and hold our children to a higher standard. Teaching my little girl to live a chaste life, saving herself until marriage, protecting her God-given gift of her human body, only to say, "Well, since I can't control you, lets go get a shot just in case you slip up on prom night" sets a horrible and contradictory example.

Ours is a sad culture indeed.

Laura Sessions Stepp: Thank you for contributing to the conversation.

_______________________

Washington, D.C.: I asked my GYN about the vaccine too and she told me the same thing as the previous poster. The vaccine would not be effective since I am 25 and have already had sex. Is it true that I've probably already been exposed to HPV, but my body just fought it off? That is what she told me.

Dr. Monique Powell Davis: You are still in the FDA approved window of 9-26. That is the age group in which efficacy of the vaccine has been studied.

If you are sexually active, there is always a risk of exposure and your body may be successful at "fighting off" the virus.

_______________________

Arlington, Va.: I was diagnosed 10 years ago, in college, with the pre-cancerous form of HPV. I came from an affluent, well educated background and was in, what I thought was, a monogamous relationship. Turns out that my boyfriend was cheating and both I and the other woman ended up with the same form of HPV. We were both treated; I had surgery to remove the cells. Now, 10 years later and 30 years old, HPV is again impacting my life. I am pregnant for the first time and I am now a high-risk pregnancy, due to my previous surgery. I have a shortened cervix and am at first for a 2nd trimester miscarriage. I can not exercise and will have to go on bed rest during my 3rd trimester. But I am the lucky one; the "other woman" can never have children because her cells were more advanced than mine at the time of treatment. Additionally, I have had four friends diagnosed with HPV in the past 2-3 years. None of whom I would label promiscuous. This is not about "it won't happen to me" -- every sexually active female will be exposed to HPV in her life. Some will feel the life long impacts, as I have. Please, get vaccinated.

Laura Sessions Stepp: Thank you for sharing this.

_______________________

Arlington, Va.: I recently found out that I have a high-risk strain of HPV. I am in a long-term monogamous relationship -- if I already have the virus, and don't plan on sleeping with anyone else, is there a reason for me to get the vaccine? Other than increasing the frequency of pap tests, is there anything else I can do?

Laura Sessions Stepp: I would check with your doctor. The vaccine protects against four strains of HPV, including two of the high-risk strains. It would be worth finding out if getting the vaccine to protect you against the other high-risk strain is worth the cost and time.

_______________________

For the Father Who Just Posted: I agree with your statements about maintaining your daughter's values. However, are you going to ensure that your daughter marries a virgin? If her husband has not also saved himself for marriage, your daughter could catch HPV on her wedding night.

Do you want to risk your daughter's dying of cancer because the future love of her love messed up when he was 19 and slept with someone else just one time before he met your daughter?

Laura Sessions Stepp: Another point of view.

_______________________

To the abstinent-minded: My father was the only person my mother had sex with and she had to have a hysterectomy at 47 because she got HPV from him. This disease is not necessarily about making choices. Wouldn't it be better to ensure that you or your child didn't have to worry about it, rather than convincing yourself that if you/they stay abstinent until marriage there's no way it could be contracted?

Laura Sessions Stepp: Thanks for sharing that story.

_______________________

Washington, D.C.: A few points of clarification: The HPV vaccination is a 3-course vaccination. As a health care professional, I am frequently encountering females who are experiencing side-effects (localized rash, fever, nausea) after the second dose. What are your beliefs as to why these side-effects are occurring? Furthermore, previous in the conversation you state that females with already diagnosed HPV should not be vaccinated. Is this a general statement for all strains of HPV or can it be specialized to the strains that the vaccination is intended to prevent? In addition, though not as severe, nothing is being said or done for males and HPV. However, HPV can still have negative ramifications for males as well.

Finally, condoms will not prevent the spread of HPV every time, and the virus can be spread when no warts or abnormalities are visible. People need to be aware of this information.

Dr. Monique Powell Davis: The HPV vaccine covers four subtypes (6,11,16,18). The subtypes associated with the majority of cervical cancer and genital warts. For that reason, diagnosis of "HPV" is not contraindication to the vaccine.

My perspective on the second dose reactions..rash, fever, nausea...I'm not sure why some patients have this response. Other vaccines can cause similar reactions which are self limiting.

Males are being studied.

_______________________

RE: Fairfax: As a health care advocate, the father from Fairfax's post illustrates exactly what is wrong with the discussion on HPV. Your daughter could do everything "right" and wait until she is married and the ONE person she may have sex with could have HPV. Would you sentence her to a life of the treatments the women who have HPV described above? As a parent how can you not want to vaccinate your child against CANCER. Not promiscuity, but cancer. The faster the general population realizes that Gardasil is solely for this purpose, the quicker we can get over the "sex" debate.

Dr. Monique Powell Davis: I concur.

We don't voice the same outrage for the Hepatitis B vaccine and it's sexually transmitted.

_______________________

Washington, D.C.: Thanks for your article, I find it incredible how blithely ignorant so many young women (and men!) are about HPV. While I have encouraged all of my friends to get the vaccine and have mostly paid out-of-pocket for myself to get it, at the same time, given its prevalence, how worked up should we get? If I had it, but it has since cleared up and have had no recurrence, should I tell future partners even though there's no way for them to know if they got it from me, or already have it? I know it's more of a moral question, but I'd be interested in knowing what Dr. Davis has advised her patients on this issue. I'm terrified that bringing this up could bring a relationship to its end, when there's no certainty it will ever be an issue.

Dr. Monique Powell Davis: That's a tough question as you say a moral one.

I strongly feel that if you know that you have HPV or any STD (Herpes, Syphillis, HIV, etc...) you should feel duty bound to discuss it with your partner. I advise my patients to be open with their partners, sooner than later.

_______________________

Takoma Park, Md.: How are men supposed to submit a clean bill of health to a prospective partner if, as I understand what you wrote, there's no test for HPV in men? I'd really like to know -- I dated a woman several years back who had genital warts, and although we were careful and used condoms, I was surprised to see that they aren't as effective in reducing transmission as would be hoped. I would like to know whether I'm a hidden carrier of these viruses.

Laura Sessions Stepp: That's a great question, and I would suggest asking a knowledgeable internist or urologist. Other than genital warts, there is no visible sign of HPV in men as far as I know. Obviously it's good to be tested for other STDs -- and only fair to tell new partners of your past girlfriend's history. Sex carries risk for even the most careful of people. There's no getting around that.

_______________________

Washington, D.C.: As safe as your scientists friends say this vaccine is, the fact is that there are not long-term studies on this drug. Doesn't it bother you just a bit that they either have or are going to make it mandatory for 12-year-old girls in D.C. to have this vaccine? It seems to be a law that disproportionately uses poor young girls as guinea pigs. Shouldn't there be a lot more education education about STDs in general and about having safe sex as well as abstinence? While a condom may only be 70 percent effective, surely that is better than not wearing one at all? I just feel like some of the push on this vaccine is to keep from having to talk about the actual STD and contraceptive ways to prevent it.

Dr. Monique Powell Davis: If mandating the vaccine as an immunization requirement for school opens the door for funding to enable more young women to protect themselves from cervical cancer, vulvar cancer and genital warts then I am all for it.

I do not agree with your perspective that young girls vaccinated are guinea pigs.

More STD education is always needed. However, it is a separate issue from the HPV vaccine. Condoms are good and better than no protection at all.

_______________________

D.C.: Could someone please answer a few questions about men and HPV.

How do we know if we have it?

Is there anything we can do to get ride of it?

What can we do to limit its spread if we do have it?

Thanks.

Laura Sessions Stepp: The only visible signs of HPV in men, to my knowledge, are genital warts. They can be treated, are not fatal, and usually disappear. But the more dangerous strains of HPV cannot be detected in men at this time -- although scientists are working on that. The only protection for intercourse at this time is the condom and it's not 100 percent. The virus has been linked to anal and penile cancer, which is one reason people should speak up for more research on men.

With this answer, we're concluding our chat. Thanks to all of you for writing in and sorry we couldn't take all of your questions. I look forward to hearing from you again in future conversations on other topics.

_______________________

Washington, D.C.: I am a 26-year-old female and, being at the high end of the age group that the vaccine is approved for, I've been doing a lot of research and want to hurry up and get it before I get too old. However, I was shocked when a couple of months ago I called both my primary care doctor and my gynecologist, only to find that neither had the vaccine and neither had any plans at the time to get it. I thought that was amazingly odd. Why is it so hard to find the vaccine? You can argue the politics of requiring it for kids all day long, but why isn't it more readily available for those of us who are old enough to decide for ourselves and want to take this small, possibly life-saving step? Also, can you be denied the vaccine if you're "too old?" In that case, would it not be as safe or effective?

Dr. Monique Powell Davis: It is effective in 26 year olds.

You can receive the vaccine after 26, but it would be an off-label use, because it is only FDA approved for 9-26 at this time.

You should ask you doctor for guidance on where to go if you want the vaccine. I have it available for my patients.

_______________________

Editor's Note: washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions. washingtonpost.com is not responsible for any content posted by third parties.