The Danger of Asymptomatic HPV in Gay Men

HPV, the sexually transmitted infection responsible for genital warts and almost all cervical cancers, is often erroneously -- and dangerously -- considered a women's health issue. In truth, HPV infects just as many men as women, and is the most common of all sexually transmitted infections. Especially when paired up with HIV.

The importance of greater awareness and safety around HPV in men, particularly gay and bisexual men, is emphasized by a recent case report calling for the U.S. Centers for Disease Control and Prevention (CDC) to expand the classification of "AIDS-defining illnesses" to include all HPV-related cancers. This includes not only nearly all cervical cancers, but 90 percent of anal cancers and significant numbers of vaginal, vulvar, penile, and oropharyngeal cancers.

"Taken together, HIV and HPV-associated cancers create a dangerous combination that requires a new definition of the best standardized treatment," said Dr. Shoreh Shahabi, chair of the Department of Obstetrics, Gynecology and Reproductive Biology at Danbury Hospital and one of the report's authors.

The case report hypothesizes that more aggressive treatment for patients with both HIV and HPV-related cancers will result in better outcomes for those patients. Since gay and bisexual men are at an elevated risk for both viruses (men who have sex with men have seventeen times the rate of HPV-related cancers as the general population), it is important to recognize their interrelation.

It is estimated that nearly all sexually active people will become infected with HPV at some point in their lives. While most infected people never show symptoms or experience any adverse effects of the virus, and most infections go away on their own within two years, a small but significant percentage of infections will lead to genital warts or a variety of HPV-related cancers -- and men should be taking steps to protect themselves and their sexual partners (whether male or female) from these consequences.

Although regular testing is generally touted as the first step to protecting oneself from sexually transmitted infections, there is, at present, there is no widely available clinical test for HPV in men. According to the CDC, "There is no general test for men or women to check one's overall 'HPV status.' Also, there is not an approved test to find HPV in the mouth or throat."

The only widely available test is for the strains that cause cervical cancer in women. Some practitioners will administer an anal Pap smear to test for the presence of anal cancer-causing HPV, especially in gay and bisexual men (HPV is responsible for an estimated 90 percent of all anal cancers). But the usefulness of this procedure is debated, and it can be difficult to find a provider who offers it.

Testing Men for HPV Must Go Beyond Symptoms to Prevent Cancer

Most health care providers will only diagnose HPV in men based on the presence of genital warts; however, since the strains of HPV that cause genital warts are not the same as the strains that cause cancer, this symptom is not useful for HPV-related cancer prevention.

In 2012, Progressive Health Services, historically a leader in HPV testing for women, began offering HPV DNA tests to men in San Diego.

"We've had many male clients who have been personally very concerned about this," said Progressive Health Services clinical director Suzann Gage, an OB/GYN nurse practitioner and licensed acupuncturist. "We've been very concerned about making this information as widely available as possible and helping people get appropriate screening."

The Progressive Health Services male HPV test is one of many possibilities being studied by researchers in the hopes of being able to offer men an easily available, FDA-approved screening process in the near future.

"It's all being done in the context of research," said Gage. "There is no standardized FDA approved test for screening because it's difficult to collect a sample; there's no standard way to do it." She did note that there are numerous non-FDA-approved tests and procedures in widespread clinical use, such as the HIV DNA test, or "early HIV test."

According to Gage, it is easier to test the cervix, anal/rectal area, or throat than to test the penis, since skin cells on the outside of the body get washed away daily. Although several methods have been attempted, Gage said that the test currently being studied by Progressive Health Services "seems to be showing that the most efficient way to is use a fine emery board that is gently stroked across the skin, and then a moist Q-tip to vigorously rub the cells off."

So far, she said, the procedure seems to be effective. Another lab in the area offers a urine HPV test, but the screening is only useful for detecting HPV in the urethra. "If the infection is somewhere else, you could miss it," said Gage. "We try to cover all the bases, so to speak."

Until HPV testing for men becomes more widely available, it is crucial that men take steps for their own protection and that of their sex partners. The FDA approved the HPV vaccine in 2009 for use on men and boys, although men are still vaccinated less frequently than women. Safer sex practices are crucial as well.

"Using condoms for vaginal, anal, and oral sex makes a huge difference," said Gage. "We know that barriers help. Even women who use diaphragms have lower rates of cervical cancer than other women, because there's a barrier present."

As HPV shifts from being considered a "women's health issue" to a concern shared by all, it will become easier and easier for men to access the care they need to keep themselves and their partners safe.