HPV IN THE MALE

hpv-kling2ALAN KLING, M.D

Dr. Kling is a recognized expert in the field of HPV treatment, Dr. Kling has lectured on HPV at Columbia, Cornell, Mount Sinai, NYU, Yale and many other medical centers, as well as at numerous national meetings. He is up-to-date on the latest advances in the diagnosis and treatment of HPV. Dr. Kling is the recognized go-to-person for HPV-related diagnoses in the metropolitan NYC area.
Dr. Kling’s private practice offices are located on the Upper East Side in Manhattan and in Park Slope, Brooklyn. The offices are comfortable, stylish, elegantly decorated and impeccably clean. You can feel reassured that your consultation and treatment will be performed by an accomplished, experienced, and well-respected board-certified physician.

Q: What is the role of the male partner in spreading HPV infections?
A: Men act as carriers of the HPV virus and need to be evaluated and treated in order to minimize the chance of infecting their partners.

Q: Why should the man be treated at all?
A: Men who are infected with HPV who have not been treated put their current p=and potential future uninfected partner(s) at risk of getting infected. Untreated genital warts on a man can also spread to new previously uninfected areas on him, which may necessitate more treatments to get the infection under control.

Q: Can the guy just wait to see if the genital warts go away on their own?
A: That would be tricky. The man continues to expose his partner(s) to an infection until the warts go away on their own and must use condoms until the infection has resolved. If the infection persists and does not spontaneously resolve, the man continues to be contagious and puts his partner(s) at risk for contracting the infection.

Q: How does a man give a woman HPV infection?
A: Most cases of HPV infections result from sexual contact. Men with HPV may have clearly evident genital warts or can be silent carriers of HPV who do not have any readily visible growths.

Q: I just started a new relationship. My former partner just contacted me and told me that they were recently diagnosed to have an HPV infection. What do I do?
A: You should go to your doctor in order to be evaluated. You have the highest chance of developing an HPV infection during the first 3-6 months after your last contact with your former partner.

Q: What do I do during that time?
A: You need to use condoms in order to protect your new partner. Your new partner may now also be at a higher risk for developing an HPV infection during the first few months of your relationship.

Q: This can be a disaster! Should I tell my partner?
A: You should be honest and inform your partner of this situation in order to decrease the chances of later accusations, bitterness and distrust which sometimes arise under similar circumstances. Your partner will appreciate the fat that you are being straightforward with them.

Q: Can I wait to see whether the new growths which I just saw will go way on their own?
A: You need to be evaluated by your doctor to see if they are genital warts, and until then to use protection at all times. Just because you see a new growth does not mean that it is a genital wart. There are many different types of growths which occur in the genital area, and many of them are benign and not contagious. You also need to e mindful of the fact that condoms do not protect against those areas not covered by the condom.

Q: How long do I wait to see whether they go away before deciding to go to see a doctor?
A: If they have not gone away on their own after 3-6 months you need to seriously consider going to a doctor and having these new growths evaluated.. The amount of time to wait is not definitive. It would be better to have them removed ASAP in order to minimize the chances of infecting a current or future partner(s) or spreading them to new previously uninfected areas on you.

Q: Do people wait?
A: Most people are generally uncomfortable with the thought of waiting once they learn that they may have a contagious condition.

Q: What do I do until the HPV is treated or until I know that they ar gone?
A: You need to do everything you can (including condoms and/or abstinence) in order to prevent spreading them to anybody else until you know that they are treated or gone.

Q: Do condoms help?
A: Condoms absolutely do help! Condoms have been shown to decrease the chances of getting an HPV infection by 70%. Condoms are not perfect, however, and only protect those areas that they cover.

Q: What areas would not be protected by condoms?
A: Areas that would not be covered by a condom and would not be protected include the base of the penis, the pubic area, the groin, thigh and lower abdomen.

Q: What does HPV look like?
A: HPV infections can be large rough-surfaced cauliflower-appearing bumps, small smooth-surfaced slightly elevated growths, flat brown or flesh-colored bumps or they can be microscopic and not readily visible to the naked eye.

Q: Can external genital warts spread when a person is not sexually active?
A: External genital warts can spread even when a person is not sexually active. The infection can spread to the normal skin around the genital wart that was not previously infected. The spread of the infection can be increased by any activity which involves friction or rubbing, like working out or wear tight fitting clothing.

Q: What should the guy do if he learns that his partner has a high risk strain or a cervical cancer?
A: The male partner should go to his doctor to be evaluated right away. He should not wait until he can easily see a growth, because growths with the high risk strains can be very small and difficult to detect. The man who is a carrier of high risk strains puts his partner(s) at risk for develop cancer of the penis.

Q: What is the nickname of men who are carriers of the high risk HPV strains?
A: Men who carry the high risk HPV strains have been nicknamed “Cancer Charlies.” The women who they come into contact with them have a statistically significantly greater chance of getting cervical cancer.

Q: Does the term Cancer Charlie refer only to heterosexual men who are carriers of high risk HPV who give it to their female partners?
A: The term Cancer Charlie is just as appropriate for gay men who are carriers of the high risk strains that can infect their male partners. Gay men have a 30x greater chance than heterosexual men of developing anal or rectal cancer, and they acquire this risk by coming into contact with gay Cancer Charlies.

Q: How common are HPV infection in men?
A: 50% – 80% of men who are sexually active in the United States have been exposed to an HPV infection by the time they are 50 yrs.

Q: Why do you see so much HPV in men?
A: Men have less of a resistance to HPV infections than women. Women create a greater number of antibodies to HPV than men and have a greater resistance to the infection.

Q: Will a person get more or fewer HPV infections as they get older?
A: The prevalence of HPV infections in woman decreases as they grow older, while the rate of infections in men remains constant as they get older.

Q: What does the term “Cancer Charlie” mean?
A: Cancer Charlie is a nickname originally given to men who are carriers of the high risk strains of HPV who transmit the infection to their female sexual partners, who subsequently will have a statistically significantly increased chance of developing cervical cancer and other HPV-related cancers.

Q: Does the term Cancer Charlie only apply to men having sex with women?
A: The term Cancer Charlie applies just as aptly to men who have sex with men (MSM). When a gay man who has an HPV infection or genital warts containing the high risk strains exposes his male partner to the infection, that partner is then at a higher risk of developing both genital warts as well as HPV-related cancers, which include cancers of the anus, rectum and/or the oropharynx.

Q: What made scientists first think that cervical cancer was caused by a sexually-transmitted infection?
A: Cervical cancer was observed to be rare in Orthodox Jewish and Muslim communities, where women were strictly monogamous . Cervical cancer was also observed to be rare in nuns, where sexual relations with men are prohibited.

Q: What were the early observations that led physicians to believe that an infectious agent might be the cause of cervical cancer?
A: A study done many years ago examined the health records of women who had died of cervical cancer. The researchers found that the second wives of men whose first wives had died from cancer of the cervix had a chance of developing a cancer of the cervix that was statistically more significant than would be normally expected. This study offered strong support to the thesis that cervical cancer may be caused by an infection.


Q: What is circumcision?
A: Circumcision is when the naturally-occurring skin that covers the penis is removed. The prepuce refers to the part of the foreskin which covers the tip of the penis.

Q: What is the role of circumcision the prevention of HPV?
A: The prevalence of both high risk and low risk HPV strains or types among circumcised men is significantly lower than in uncircumcised men. Circumcised men do not develop genital warts or condyloma as frequently as uncircumcised men, and their partners have a lower chance of contracting an infection from them. Genital warts in uncircumcised men also recur more frequently than in circumcised men.

Q: How does the circumcision status of the man affect the woman’s chance of getting cancer of the cervix?
A: There is a higher chance of a woman getting cancer of the cervix after sexual contact with a man who is uncircumcised compared to a man who is circumcised.

Q: How much less frequently do the different HPV strains occur in men who are circumcised?
A: Both high-risk and low-risk HPV types occur 20%-70% less in circumcised men compared to uncircumcised men.

Q: Why is there an increased chance of a woman getting cancer of the cervix from an uncircumcised man?
A: The uncircumcised man is more likely than the circumcised man to be harboring the high risk strains of HPV.

Q: Why is an uncircumcised man more contagious than a circumcised man?
A: The foreskin that is present in an uncircumcised man gets easily traumatized. Multiple small breaks occur on the foreskin, HPV gets under the skin through these breaks and an infection is established.

Q: Why is the foreskin so easily infected?
A: The foreskin provides an increased surface area that the HPV virus can infect. Infections on the foreskin are much more resistant to treatment and are associated with increased recurrences after treatment compared to treatment in circumcised men.

Q: What happens when the foreskin is removed?
A: When the foreskin is removed the area of the skin that was previously more prone to get traumatized and infected is no longer present after a circumcision. Circumcised men have a lower chance of being carriers for HPV and of transmitting the infection compared to uncircumcised men.

Q: What happens to the penis after the foreskin is removed?
A: The skin on the penis gets thicker after the foreskin is removed. The thicker skin is a more effective barrier against HPV, as well as other infections. Chlamydia, for example, which is a co-factor that promotes the chance of a man getting an HPV infection, is also less likely to occur in the circumcised man.

Q: Are there any other benefits to circumcision?
A: The malodorous accumulation of the cheesy material under the foreskin known as smegma does not occur in men who are circumcised. There is less odor in the genital area when the man is circumcised because is easier to keep the area around the penis clean. Men who are uncircumcised complain that it can be virtually impossible to maintain good penile hygiene regardless of how often they wash themselves during the day. This odor is not infrequently an issue for both the men and their partner(s).

Q: What would you expect to occur after a man is circumcised?
A: The circumcised man will have a lower chance of getting or transmitting an infection with both the high and low risk HPV strains.

Q: How are the chances of a woman getting an HPV infection affected by the circumcision status of her male partner?
A: Women who are exposed to men who are carriers of high-risk HPV viruses are less likely to acquire infection if their male partner is circumcised.

Q: Why are men who are not circumcised more likely to get an HPV infection than men who are circumcised?
A: Men who are not circumcised are more likely to get an HPV infection than men who are circumcised because more breaks occur on the fragile foreskin through which the HPV virus can establish an infection. The heat and moisture under the foreskin also creates a more hospitable environment in which the HPV virus can grow and thrive.

Q: Are HPV infections in uncircumcised men more difficult to treat?
A: HPV infections in uncircumcised men are more difficult to treat, have higher recurrence rates and are more likely to infect a partner than are infections in circumcised men.

Q: What is the status of male circumcision in the United States today?
A: The number of uncircumcised males in the United States is increasing. The initial trend after World War II was to circumcise males shortly after birth because it was believed that this would result in better hygiene and better health. Although the role of circumcision in preventing infections and certain unwanted medical conditions is acknowledged, the views encouraging circumcision are not as adamant as they had once been.. As a consequence, more parents are now choosing not to circumcise their sons.

Q: Are there any other reasons why the number of uncircumcised men in the United States is increasing?
A: Over the last several decades there has been increased immigration from Asian and Hispanic countries, where circumcision is not routinely practiced and it is not part of the culture. These groups tend to carry on the family tradition of not getting circumcised. Whereas before there used to be firm healthcare guidelines unequivocally encouraging parents to circumcised their sons, the Department of Health has taken and is now offering a more watchful waiting and active surveillance approach.

Q: How will the increasing numbers of uncircumcised men in the United States affect the prevalence of HPV infections?
A: There will most likely be an increased incidence and spread of HPV amongst the female and male population exposed to men who are not circumcised. HPV infections in uncircumcised men have been associated with a greater number of lesions, more extensive involvement and higher rates of recurrence compared to infections in men who are circumcised.

Q: How often do men decide to get circumcised as adults in order to get an HPV infection under control?
A: The rate of circumcision in adult men is very low. Adult men who decide to get circumcised usually have other additional issues which make circumcision advisable. Adult men who decide to get circumcised in order to manage especially resistant and recurrent HPV infection s are rare.

Q: What can a man who is not circumcised and/or his partner do in order to minimize their chances of getting an HPV infection?
A: The HPV vaccine would be an especially helpful and valuable approach to minimize the chance of an HPV infection in men who are not circumcised and in their partners.

Q: Will the HPV vaccine help treat an uncircumcised man and/or his partner who are already infected with HPV
A: The HPV vaccine works well to protect a person against those strains of the virus which are in the vaccine to which they have not been previously exposed, but will not give increased immunity against those strains of the virus with which they have already been infected. The vaccine is preventive and not therapeutic. The vaccine will not help a current infection that has already been established.

Q: What percentage of men in the United States are circumcised?
A: According to the CDC (Center for Disease Control), the circumcision rate for newborn infant males in the United States has experienced a significant decrease over the last several decades. 32% of male infants born in the United States in 2009 were circumcised, compared to a 56% circumcision rate in 2006 and a rate that was over 80% in the 1970’s and the 1980’s.

Q: What were the previous circumcision rates in the United States for infant boys?
A: The circumcision rate in infant boys in the United States peaked in the 1970’s and 1980’s when over 80% of newborn male infants were circumcised.

Q: Are there regional differences throughout the United States?
A: There are regional variation in circumcision rates. The western Untied States has the lowest rate of infant circumcision, ar below the national average of 32% in 2009. Circumcision rates tend to be high in areas with significant Jewish and Muslim populations, where circumcision is traditionally associated as part of the religious and cultural practices of these groups.

Q: Is the percentage of circumcised males in the United States going up or going down?
A: The percentage of males in the United States continues to decline.

Q: What is the medical profession’s recommendation on circumcision?
A: The American Academy of Pediatrics (AAP) released a statement (August 27, 2012) that states that new scientific evidence shows the health benefits of newborn male circumcision outweigh the risks of the procedure, but the benefits are not great enough to recommend routine circumcision for all newborn boys.

Q: What are the scientific research show?
A: Scientific research shows that circumcision offers clear health benefits that includes lower risk of acquiring HIV, genital herpes, human papillomavirus and syphilis. Circumcision also lowers the risk of penile cancer over a lifetime, reduces the risk of cervical cancer in sexual partners, and lowers the risk or urinary tract infections in the first year of life.

Q: Would you expect a position more strongly favoring circumcision by the American Academy of Pediatrics based on this data?
A: The scientific evidence and medical advantages of circumcision are clear. Circumcision is an emotional decision for many parents. No turnaround in the circumcision rate will occur unless a prestigious and respected organization like the American Academy of Pediatrics or a federal agency or organization takes a firm and clear position on the issue based on health considerations. The American Academy of Pediatricians has punted and taken the politically-guided noncommittal position that the decision should be made by the parents in the context of their religious, ethical and cultural beliefs.

Q: How does the circumcision status of the man affect his chances of getting an HPV infection?
A: Uncircumcised men have a greater chance of contracting an HPV infection.

Q: How does the circumcision status of the man affect his female partner’s chances of getting an HPV infection?
A: A woman has a higher chance of getting an HPV infection from a man who is uncircumcised than from a man who is circumcised. The circumcision status of the man is one of the important co-factors in the male partner that affects a woman’s chance of developing HPV infections and cancer.

Q: How do the treatment results compare in men who are circumcised compared to those who are uncircumcised?
A: Men who are not circumcised have a higher chance of getting recurrent HPV infections after treatment compared to men who are circumcised.

Q: Does the circumcision status of the man affect the number of treatments the man will need in order to get their infection under control?
A: Men who are uncircumcised usually require a greater number of treatments in order to get their HPV infection under control compared to men who are circumcised.

Q: How does the rate of transmission of HPV to their partner(s) compare in men who are circumcised compared to men who are not uncircumcised?
A: The rate of HPV transmission is decreased in men who are circumcised.

Q: Should men who are uncircumcised who have HPV infections get a circumcision?
A: Men who are uncircumcised should not be routinely advised to get a circumcision . The infection can be managed and contained with traditional treatments and diligent follow up evaluations. Circumcision should be reserved as an option only for the most extreme of cases.

Q: How does a man’s circumcision state affect the chances of him getting an HPV infection?
A: Men who are not circumcised have up to a 30% increased chance of getting an HPV infection.

Q: Is there any difference in the man’s response to treatment if he is circumcised compared to if he is not circumcised?
A: There is a 30% increased persistence rate of HPV infections in men who are not circumcised compared to men who are circumcised.

Q: Do men who have an HPV infection also need to be monitored?
A: Men who had an HPV infection need to continue to be monitored because there is a high risk of recurrences with HPV infections. Men need to take precautions so that they do not infect or reinfect their current partners or a potential future previously uninfected partner.

Q: If two people are in a monogamous relationship and one of the individuals is recently diagnosed with an HPV infection, does this mean that their partner is cheating on them?
A: Nobody can tell for certain when they first got the infection. A person could have been infected years ago and their immune system adequately suppressed the virus so that it was able to stay in a dormant state. This very same person may now be tired, worn down, under stress, have a chronic illness or any one of a number of different factors that decrease their immunity and enables the virus to grow and proliferate. You simply cannot tell for certain when the infection first began.

Q: Wouldn’t the person know if they had been exposed to HPV?
A: Most people who have HPV do not have any signs or symptoms of an infection and are unaware of the fact that they have been infected. They may then unintentionally expose their current and/or future partner(s) to HPV, and these newly infected individuals may then unintentionally expose their current and/or future partners to HPV. This explains why HPV is present in such epidemic proportions.

Q: What is the most common way of spreading the infection from one person to another?
A: The most common means of transmission is from skin-to-skin transmission where there is asymptomatic shedding, where viral particles are spread from the infected partner to the uninfected partner.

Q: The fact that I got an HPV infection from my partner is very upsetting to me. Should I get out of the relationship?
A: Over 50% and in some instances up to 80% of sexually active people in the United States have been exposed to the HPV virus by the time they are 50 yo. You should both move on and be evaluated and if needed treated. The relationship should be preserved or severed based on the merits of the relationship, not on the basis of whether an almost ubiquitous infection has been identified.

Q: Does a person who had a previous HPV infection(s) build up an immunity against future HPV infections?
A: Women who are exposed to the HPV virus are able to produce more protective antibodies against HPV than men, and the number of HPV infections in women as they get older declines. The frequency of HPV infections after exposure in men stays constant, indicating that men are less likely than women to build up a resistance to the infection.

Q: Are men more likely to get recurrences of HPV infections than women?
A: Men get more frequent recurrences of HPV infections than women. The incidence of HPV infections in men remains constant because they are not able to mount as vigorous an antibody response to HPV as women.

Q: What are risk factors for HPV infection in men?
A: The main factors that put a man at greater risk of acquiring an HPV infection are a history of multiple partners, lack of circumcision, lack of condom use, history of other sexual transmitted infections, smoking and exposure to second-hand smoke.

Q: What is the one factor that puts a man at greatest risk of having an HPV infection?
A: The most consistently reported risk factor HPV infection in men is a the lifetime number of sexual partners. The number of recent sexual partners is particularly important.

Q: What is the association between economic status and the chances of getting an HPV infection?
A: Men who are of a higher economic class have a decreased chance of getting an HPV infection.

Q: What are the protective factors against HPV infection in men?
A: Factors that are protective for a man against HPV infections include condom use, being circumcised, not smoking, not being exposure to second-hand smoke, and higher economic status.

Q: What is the association between HPV and tobacco?
A: Men who smoke have a higher chance of getting an HPV infection.

Q: What does the term persistence mean?
A: Persistence refers to HPV infections that do not resolve on its own. Most HPV infections do resolve on their own.

Q: Are there any particular conditions that increase a person’s chance of having persistent HPV infections?
A: Infection with high risk strains and multiple HPV types increase the chance of a person having a persistent infection.

Q: Are there any protective factors associated with not getting persistence?
A: Circumcision has a protective effect against HPV persistence.

Q: What are the protective factors that help minimize a person’s chances of getting an HPV infection?
A: Factors associated with a decreased chance of getting HPV infections include fewer number of sexual partners, condom use, the man being circumcised, being a non smoker, negative history of second-hand smoke exposure and higher socioeconomic status.

Q: What is the single factor that puts a man at the greatest risk for getting an HPV infection?
A: The man’s chances of getting an HPV infection are directly related to his lifetime number of sexual partners.

Q: What is the advantage to women if men get vaccinated?
A: Men are frequently carriers of the HPV virus. A carrier refers to a person that has an infection and sheds the virus which can then infect their partner(s). If men are vaccinated before they have gotten an HPV infection there is less of a chance of them acquiring it at a later date and infecting their female (and male) partner(s).

Q: Should men get vaccinated just so that they can decrease the chance of giving their female partners an HPV infection?
A: That is an important reason but not the only reason. Men should get vaccinated in order to minimize their own chances of getting an HHPV infection as well as HPV-related diseases, including cancers of the penis, anus, rectum, and the oropharyngal area. A man who is vaccinated also has a decreased chance of acquiring a new infection, and will therefore be less likely to infect their current and/or future partner(s). The advantages and multiple positives of getting an HPV vaccination will have a positive impact on their lives.

Q: Any other advantages for the man to get vaccinated?
A: The man who is vaccinated will be able to avoid the psychological aspect of having a sexually transmitted disease. He will avoid the embarrassment of the uncomfortable situation of needing to inform a current or future partner that he has or had an infection. Not getting the infection will allow him to avoid the hassle and time needed to set aside to visit doctors. and the cost of doing so.

Q: Is the HPV vaccine expensive?
A: The vaccine is not inexpensive, but is covered by insurance for men up to the age of 21-26 years of age. The long term expense, time, and the emotional and psychological hassles associated with an active and/or potentially latent HPV infection makes the cost of getting the vaccine appear to be inconsequential. The vaccine gives a person the best bang for the buck from the medical, social and psychological point of view.

Q: What kind of HPV-conditions can a man get?
A: Men can get genital warts as well as cancers of the penis, anus, rectum and oropharyngeal area.

Q: What is the most common HPV-related condition that a man can get?
A: The most frequently seen HPV-related condition that men can get are genital warts. Genital warts are usually caused by low risk HPV strains. HPV strains 6 and 11 are the most common HPV strains, and represent 90% of the causes of genital warts.

Q: What kind of cancers can a man get caused by HPV and which strains cause them?
A: In men, HPV causes cancers of the penis, anus and rectum that are associated with the high risk strains of HPV. HPV 16 and 18 represent about 70% of the HPV strains that cause these cancers. Cancers of the oropharyngeal region are also seen more frequently in men, and those cancers are caused almost exclusively by HPV 16 alone.

Q: What kind of effectiveness has been observed in women who got the HPV vaccine in the long term?
A: Australia had provided free HPV vaccines to 12-18 year old girls in a school-based program. Researchers observed that the proportion of women under 28 years old with genital warts decreased by 25%.

Q: How was the frequency of the occurrence of HPV infection in heterosexual men affected when only girls were vaccinated?
A: Heterosexual men had a 5% decrease in genital warts.

Q: Why did heterosexual men who were not vaccinated experience a decrease in their chances of acquiring an HPV infection when only the girls were vaccinated?
A: This observed effect is the result of the “herd immunity. ” The efficacy of the HPV vaccination in females led to less of a reservoir of the HPV virus in women that was available to infect heterosexual men.

Q: Was this herd immunity effect seen in all heterosexual men?
A: The decreased incidence of genital warts was seen predominantly in younger heterosexual men. Younger men tend to have sex more frequently with women their own age or younger. If these women were already vaccinated and immune to HPV at the time that they sexual contact with an older male partner who already had an HPV infection, they will not get the infection and cannot subsequently infect a guy their own age with whom they have sexual contact.

Q: Was there any advantage to gay men when women were vaccinated?
A: Gay men did not gain any improved chances of a lower chance of getting genital warts when women alone are vaccinated.

Q: How do you also protect the gay population from HPV infection?
A: Widespread vaccination of all men will most likely result in a statistically decreased occurrence of HPV infection in both heterosexual and gay men and will provide protection against both genital warts and the numerous HPV-related cancers.

Q: Should all men be vaccinated?
A: There is an enormous advantage for all men (heterosexual and gay) to get vaccinated. Being immunized against HPV infections decreases the man’s chances of getting HPV infections that can cause genital warts as well as any one of numerous HPV-related cancers. Men will also be spared the medical, psychological, social and economic penalties of having an HPV infection.

Q: Why do we hear so much about HPV and vaccination in women but so little about HPV and vaccination for men?
A: Most of the pioneering work on HPV was done by physicians and scientists who were concerned about the association of HPV with cancer of the cervix. Women had a naturally occurring advocacy group in this regard. Physicians were searching for better ways to improve the early diagnosis and treatment of women with high risk HPV and with precancerous and cancerous lesions. Research in the field of HPV exploded and once a certain level of understanding of the HPV virus was achieved a vaccine was developed.

Q: What were the initial concerns about men with HPV?
A: The attention to men with HPV focused on men as being carriers of the HPV virus that could infect women. The interest in men was related to the importance of the male factor in causing cancer of the cervix. There was little discussion of the direct health issues men might have if they were infected with HPV until recent years.

Q: Why was the field not looking closely at the effect of HPV on men?
A: The HPV field is strongly oriented towards the prevention and treatment of disease in women. When HPV infections at other sites are always initially examined using the research models perfected through the study of cervical cancer. Historically, relatively little attention in the HPV literature has been devoted to the diagnosis, treatment and prevention of HPV infections in men.

Q: When was the HPV vaccine for men developed?
A: The HPV vaccine was demonstrated to be safe and effective in women. The vaccines were subsequently FDA approved for use in the United States for women. Gardasil (Merck) was approved as a vaccine for women in 2006 and Cervarix (GSK) was also approved as a vaccine against HPV. Merck subsequently submitted data demonstrating that their HPV vaccine (Gardasil) was also safe and effective in men and Gardasil was approved for men in 2009.

Q: Was the HPV vaccine for men developed in order to address concerns about the effects of HPV in men?
A: The main driving force of the medical and scientific community as well as the marketing strategy for the vaccine companies was to get men vaccinated in order to decrease the number of men in the population who can infect women. The data submitted to the FDA for approval of the HPV vaccine (Gardasil) for men demonstrated that the vaccine decreased the incidence of genital warts in men and also decreased the incidence of a precursor growth of anal cancer.

Q: Why are we now hearing more people encouraging men to be vaccinated?
A: The main concern of the gynecologic community, who are the natural advocacy group of women, is to increase the protection of women from HPV. In recent years it has been increasingly recognized that if men are also given the opportunity to be vaccinated there would be a decreased prevalence of HPV in both the female and male population.

Q: Why didn’t they advocate that men should also be vaccinated as soon as the vaccine was available?
A: The initial plan was to decrease the total amount of HPV in young women by having women exclusively vaccinated. Not enough women volunteered to receive the full three shots of the vaccine, which would not only protect them but also establish a significant herd immunity response in the population that would result in a significant decrease in the prevalence of HPV in the general population. Men therefore also needed to be targeted to be vaccinated, in order to decrease the amount of HPV in the general population so that fewer women would be exposed. There has subsequently been an increased recognition of the importance of addressing the numerous HPV-related infections, precancers and cancers which occur in men, and an appreciation of how the vaccine may also help to prevent these conditions.

Q: How percentage of women do physicians think need to be vaccinated in order to make a significant impact on the immunity of the entire population against HPV?
A: Although the HPV vaccine is recommended for girls up to 21 years of age (up to 26 years old under certain circumstances), only 35% of the female population in those age ranges in the United States had received all three vaccinations. 70+% of women need to be vaccinated in order to get a significant herd immunity effect in the entire population.

Q: Was vaccinating men a consideration early on?
A: The vaccine is very expensive. Health care economists and government policy scientists determined that the most cost effective way to protect women from getting an HPV infection would be to focus their efforts solely on getting as many females of the appropriate ages vaccinated. Vaccinating men was initially considered a non-cost effective approach to decreasing the incidence of cervical cancer in women so men were not initially targeted to get the vaccination.

Q: What consideration was given for the potential advantages to men of being vaccinated?
A: The protection of men against HPV infections including genital warts, and HPV-related cancer was not initially the main focus of discussion. The discussion was focused on how to achieve the greatest amount of protection for women.

Q: What is the long term advantage of HPV vaccination in reference to decreasing the chances of cancer?
A: The HPV vaccine has been demonstrated to effectively prevent the growth of cervical cancer precursors caused by high risk HPV DNA in women. Studies were designed to detect the appearance of cervical cancer precancers as an endpoint because it would be unethical to wait to allow a cervical cancer to develop. Protection against genital warts caused by low risk strains was also demonstrated. The decrease in the incidence of both precancerous growths and genital warts indicated that the vaccine is effectively boosting the immune system against both the high and low risk strains of HPV in the vaccine.

Q: What evidence is there that the HPV vaccine will also protect against HPV-related cancers?
A: The incubation period for the HPV virus to grow out into genital warts is 3-6 months. The fact that there is a significant decrease in genital warts indicates that the vaccine is working. Cervical cancer takes 20-30 years to develop from the time of the initial HPV infection. Other HPV-related cancers in differ anatomic locations (anus, rectum, oropharynx, penis) also take a long time to grow . The decreased incidence of precancerous lesions is taken as a proxy and encouraging suggestion that the long term incidence of other HPV-related cancers similarly caused by the high risk strains may also be decreased. The increased protection against the high risk strains of HPV should also decrease the chances of the development of other HPV-related cancers.

Q: Are studies currently being done on the effectiveness of the HPV vaccine in preventing the development of HPV-related cancers?
A: Long term studies of the effectiveness of the HPV vaccine against numerous HPV-related cancers are underway. The final data will not be available for many years because HPV-related cancers can take 20+ years to grow out. The preliminary data will be released intermittently as the results come in.

Q: What are the conclusions from the Australian study of young women who had received the HPV vaccine?
A: The marked the reduction in the occurrence of genital warts in women in the year following vaccination supports the efficacy of the vaccine. The reduction in genital warts among non-vaccinated heterosexual men but not among non -vaccinated gay men is consistent with reduced heterosexual transmission of HPV as a result of female vaccination due to herd immunity.

Q: What screening methods can be used in men to detect whether they have an HPV infection?
A: The relatively simple and straightforward screening methods available to women are not available to men. Men who see or feel a growth(s) in their genital area or who have been informed by their partner that they have an infection need to be evaluated by their physician in order to determine their status.

Q: Is there a blood or urine tests that serve as a screen for HPV infections?
A: There is no effective blood or urine test for HPV in either men or women.

Q: Do men have a greater chance of getting genital warts than women?
A: Men develop genital warts more frequently than woman.

Q: Why do men develop genital warts more frequently than woman?
A: Women are able to mount a more robust antibody level response to HPV infections than men, which gives them a higher resistance to infection.

Q: What is the difference between a man and a woman’s immunity to HPV?
A: Men do not develop antibodies as frequently as women, and when they do they have lower antibody levels.

Q: Why are men not able to produce antibodies as effectively as women?
A: The body has a much more difficult time forming antibodies against growths on the surface of the skin (i.e. penis) than on moist surfaces (i.e. vagina, cervix).

Q: Are the numbers of anal and rectal cancers increasing?
A: The incidence of anal and rectal cancers is increasing in heterosexual and gay men as well as in women. The rate of increase of anal and rectal cancers in gay men is especially high and this is worrisome.

Q: How does the number of cases of invasive cervical cancer in women compare to the cumulative number of HPV-related cancers which occur in men?
A: The screening methods against cervical cancer in the United States have driven down the incidence of invasive cervical cancers to a number that is lower than the cumulative number of HPV-related cancers which occur in men. The continued screening of women for cervical cancer continues to be of critical importance.

Q: How common are anal and rectal cancers in the gay community?
A: Anal and rectal cancers are 30x+ more frequent in gays compared to heterosexual men. These cancers are also more aggressive and more resistant to treatment in gays when compared to heterosexual men.


Q: What is the relative frequency of anal and rectal cancer in the HIV+ population compared to the heterosexual population?
A: The incidence of anal and rectal cancer in the HIV+ population is 70x+ high in gay men than in heterosexual men.