Human papillomaviruses (HPV) are the subject of the cover article of AFP's November 15th issue, authored by Drs. Gregory Juckett and Holly Hartman-Adams from the West Virginia University Robert C. Byrd Health Sciences Center School of Medicine. While "low risk" HPV types 6 and 11 cause up to 95 percent of genital warts, "high risk" HPV types 16 and 18 cause the majority of cervical cancers. In recognition of these risks, the American College of Obstetricians and Gynecologists recently recommended that women older than 30 years receive high-risk HPV DNA testing in addition to cytology for cervical cancer screening.
Previous issues of AFP reviewed the efficacy of the quadrivalent HPV recombinant vaccine and recommendations for its administration by the American Cancer Society and the CDC's Advisory Committee on Immunization Practices. HPV vaccine is only the second cancer-preventing vaccine, after hepatitis B vaccine (which prevents liver cancer). However, Drs. Juckett and Hartman-Adams observe in their article that implementing HPV vaccine recommendations has been challenging:
Controversy about HPV vaccination involves its high cost (approximately $150 per injection), uncertain duration of protection, and concerns that it provides tacit approval of sexual activity and a false sense of security. In addition, the necessity of vaccinating girls as young as nine to 11 years, before they become sexually active, unsettles many parents. There has been criticism for aggressive marketing of HPV vaccine to older women already exposed to HPV, while less attention has been given to the subpopulations at highest risk.
AAFP News Now recently reported that HPV vaccination rates in 2009 varied widely from state to state, with 44.3 percent of teenage girls nationally having received at least one dose and 26.7 percent having completed the 3-dose series. Just last week, a U.S. Food and Drug Administration advisory committee meeting reviewed the evidence that HPV vaccination prevents anal cancer in men who have sex with men. How the committee's reported decision to approve HPV vaccine for this indication will affect future national recommendations for vaccination in males remains to be seen.
How has the availability of HPV vaccine affected your practice? What approach do you take in discussions with adolescents and parents? We would love to hear about your experiences.