Download Who*s afraid of the big bad wolf?: Understanding Human Papilloma

Who’s afraid of the big bad wolf?:
Putting Human Papilloma Virus (HPV) in Perspective
Nikole D. Gettings, RN, MSN, CNM, APN
Clinical Services Coordinator
901-274-3550
[email protected]
GRATITUDE
• Brenda Kyles, Regional Program
Coordinator, Shelby County Health
Department
• Rebecca Terrell, Executive Director
• Jennifer Pepper, Assistant Director
• Katy Leopard, Community
Partnerships Coordinator
Association of Reproductive
Health Professionals
OBJECTIVES
• Present CHOICES Reproductive Health services;
highlight services related to Human Pappiloma
Virus [HPV], PAP Smears, and colposcopies
• Discuss HPV impact on public health
• Understand how microbiology of HPV results in
health outcomes related to HPV
• Review current screening guidelines and clinical
testing related to HPV
• Review public health messaging around HPV
•
Birth Control Consults: $50.00 Cash Pay or Bill Insurance
–
–
–
–
–
–
•
STD Testing: Women, Men, Adolescents:
At least Once Per Year and Every time you have a new Partner
–
–
–
•
Free HIV Ora Quick: 20 minute results
$50.00*Urine/Blood GC/CT, RPR, HIV
$85.00* GC/CT, RPR, HIV and HSV I & II Typing
Clinical Consults: Cash Pay Prices Vary or Insurance ~We take TNCARE~
–
–
–
–
–
–
–
–
–
–
–
•
•
IUD: Mirena and Paragard Insert and Removals
Implanon: Insert and Removals
Depo: $30 .00* On Site
Prescriptions and counseling on the Pill, Patch, Ring
Counseling and Guidance for Fertility Awareness Method
Free CONDOMS in waiting area
Female Reproductive Health including Annual Gynecologic Visit and Problem Visits as needed
Male Reproductive Health
Adolescent Reproductive Health
HIV Positive Reproductive Health * Ryan White Service Provider Reproductive Health *
HIV PREP Counseling and treatment
Wart Treatment
HPV: Counseling, testing and treatment
Infertility Evaluation and 2nd opinions
Fertility Counseling and assistance including same sex, known donor and single women
Transgender Hormone Management and Reproductive Health
Colposcopy: ~TN Breast and Cervical Cancer Referral Site ~ and Cash Pay Prices available ($250.00 - $350.00*) including lab fees
Reproductive Health Office Hours: Monday, Tuesday, Thursday and Friday 9:00 AM – 5:00 PM
Visit our website for additional services and lots more information: www.memphischoices.org
*All Price quotes subject to change, call office for most up to date pricing information and to schedule appointment
Big Bad Wolf
HPV: Mythological Creature
What are we afraid of?
Do You Have HPV?
“HPV is so common that nearly all
sexually active men and women will
get at least one type of HPV at some
point in their lives.”
HPV: Mythological Creature
Fears
Myths
What Does Sex Have to do with it?
HPV Facts
Meet the Virus: Common Viruses
•
•
•
•
•
•
•
•
•
Flu Virus
Common Cold
Hepatitis
Polio
HIV
Measles
Chicken Pox
Mumps
Rubella
Meet the Virus: HPV
150 + Types
HPV Types: Low Risk and High Risk
GENITAL HPV
Who Has HPV
High Lifetime Risk of HPV Infection
• 6.2 million new infections
• NHANES 2003-2004 reports a prevalence
rate of 26.8% in US females age 14 -59
• Approximately 75% lifetime risk for
sexually active individuals
Cates W. Sex Transm Dis. 1999; Weinstock H. Perspect Sex Reprod Health. 2004;
Koutsky L Am J Med 1997; Dunne EF. J Infect Dis. 2006; Dunne EF. JAMA. 2007.
New HPV Infection is Common in
Young Women
Study of 603 female college students
• About 20% were HPV positive at entry
• Almost 40% converted to positive within
24 months
Winer RL. Am J Epidemiol. 2003.
Prevalence of HPV in Men
• HPV prevalence in men ranged from 1.3% to
72.9%.
• Most studies (56%) showed ≥ 20% prevalence
more…
Dunne EF. J Infect Dis. 2006.
Not Just People
Where Does HPV Come From?
Skin and Friction
What Does HPV Look Like?
HPV: What Does it Look Like?
Most people with HPV never develop
symptoms or health problems.
Where there is Skin, there is HPV
Epithelial Cells
Transformation Zones and HPV
Infection
• Area where one type of epithelium
contacts and gradually replaces another
through process of metaplasia
• Present in cervix, anus, tonsils
• Areas of HPV-related carcinogenesis
Moscicki AB. Vaccine. 2006.
HPV: What is all the fuss?
Virus Microbiology
Viral Relationships: Virus + HOST Cell =
MORE VIRUS
Viral Relationships: HPV and Epithelial
Cells
Viral Relationships: HPV and Cancer
Tumor Suppression Cell Deactivation
Most HPV infections (90%) go
away by themselves within
two years
HPV Necessary for Cervical Cancer
Transmission: genital skin to skin contact
Transient HPV
infection
Low grade lesions:
CIN 1/LSIL
(Episomal HPV, koilocytotic
atypia, mild dysplasia, lesion
extends to less than 1/3 of the
epithelium, most lesions regress)
Persistent infection with
oncogenic HPV types
High grade lesions: CIN 2-3/HSIL
(HPV integrates into the genome, genomic
instability, moderate or severe dysplasia, extension
to full thickness of the epithelium, regression less
frequent than for CIN 1)
Invasive cervical carcinoma
(Disease extends beyond basement membrane and invades connective
tissue, metasatic spread to lymph nodes and distant sites)
Trottier H. Vaccine. 2006; Ley C. J Natl Cancer Inst. 1991.
Cofactors:
• Oral contraceptive
use, other hormonal
influences
• Parity
• Other STIs
• Smoking
• Nutrition
• Host genetics:
Polymorphisms in
HLA and other
genes
• Viral genetics:
Genotype,
molecular variants
HPV + ??? = Cancer
HPV-Associated Health Related
Outcomes
• Anogenital cancers
– Cervical
– Anal
– Vulvar and vaginal
• Other cancers
• Oral cavity, pharynx, larynx
• Skin
• Conjunctiva
• External genital warts
• Laryngeal papillomatosis
Munoz N. Vaccine. 2006; Lacey CJN. Vaccine.2006.
HPV: Where Are We
• HPV is Common
• HPV affects epithelial (skin) cells
– Low risk = Warts
– High risk = trigger for cancerous growths
• Genital
• Cancer is rare
HPV: What can we Do about It
HPV What Can We Do About It?
• Primary Prevention
– Education
– Vaccination
• Secondary Prevention
– Screening
• Tertiary Prevention
– Treatment
Primary Prevention: Decrease Fear
Primary Prevention: Encourage
Healthy Lifestyles
Primary Prevention: Vaccination
Primary Prevention: Vaccination
Secondary Prevention
• Cervical PAP Screening
– Colposcopy Screening
•
•
•
•
Anal PAP Screening
HPV Screening
Dental HPV Screening
Dermatology Skin Screening
Secondary Prevention: PAP Screening
Cervical and Anal
Guidelines: Cervical Cancer Screening
Recommendation Agencies
Agencies
American College of Obstetricians and Gynecology
US Preventative Task Force
ASCCP
American Cancer Society
Saslow D. CA Cancer J Clin. 2002; ACOG Committee on Practice Bulletins. Obstet Gynecol.
2003; USPSTF. Screening for Cervical Cancer: Recommendations and Rationale. 2003.
Guidelines: Cervical Cancer Screening
Recommendation
Consensus
• Do not conduct Pap smear before age 21
• Age 20-30: Every 2-3 years (if normal)
• After age 30:
– Normal, but HPV Positive: Every 2-3 Years
– Normal, HPV Negative: Every 3-5 Years
• Stop: 65
• In the case of Abnormal at any time: Follow up
recommendations vary
Saslow D. CA Cancer J Clin. 2002; ACOG Committee on Practice Bulletins. Obstet Gynecol.
2003; USPSTF. Screening for Cervical Cancer: Recommendations and Rationale. 2003.
2007 Anal Cytology Screening
Recommendations
• Routine anal cytology screening is NOT
recommended by CDC, USPSTF, ACS, or ISDA
• National Guidelines Clearinghouse has no
guidelines for anal cytology screening
• However New York State Department of Health
now recommends anal cytology for HIVinfected individuals who: 1) are MSM, 2) have
had genital warts or 3) have had CIN
New York State Dept of Health. www.hivguidelines.org.
Secondary Prevention: HPV Testing
Clinical Uses of HPV Testing
• Test only for high-risk HPV types
• Adjunct to cytology for screening women >30
years old
• ASC-US management in women age >21 years
old
more…
Adapted and printed with permission from ASCCP Educate the Educators:
HPV and the HPV Vaccines © 2006, ASCCP. All rights reserved.
Clinical Uses of HPV Testing (Continued)
• Follow-up after colposcopy evaluation of
abnormal cytology
• Follow-up after treatment of CIN 2/3
• To triage menopausal women with LSIL
Adapted and printed with permission from ASCCP Educate the Educators:
HPV and the HPV Vaccines © 2006, ASCCP. All rights reserved.
Secondary Prevention: Pap Follow Up
with Colposcopy
Secondary Prevention: STD Screening
Secondary Prevention: STD Screening
Recommendations
Once Per Year
New sexual partner
Gonorrhea
Chlamydia
HIV
Syphillis
SYMPTOMS
Tertiary Prevention: Treatment
• Counseling
• Treatment
Tertiary Prevention: Treatment
Management of Abnormal Pap Results
Cytology
Normal
Repeat in 6 months. After
two consecutive normal
results, screen annually
ASCUS: 3 options
ASC-H
Refer for colposcopy
LSIL or HSIL
Refer for colposcopy
AGUS
Refer for Colposcopy
Counseling Women with HPV
Remind your patient that:
• Most women will have HPV at some point
• There is no way of knowing how long HPV has
been present
• Having HPV is not a sign of infidelity
more…
Counseling Women with HPV
(Continued)
Also remind your patient that:
• Most women who have HPV do not develop
abnormal cells of cancer
• Women who have HPV in their cells a long
time are at greater risk for developing
abnormal cells or cancer
Tertiary Prevention: Warts
• Medication: Provider Applied or Patient
Applied
• Cryotherapy
• Excision
Tertiary Prevention: Treatment of
Cancer
•
•
•
•
•
Cryotherapy
LEEP
Cone
Excision
Hysterectomy
HPV Educational Messages
•
•
•
•
HPV is sexually transmitted
HPV is very common
Most women with HPV will not get cancer
HPV infection usually clears without
treatment
• Pap tests are used to detect HPV-related
pre-cancers
more…
Monk BJ. Cancer. 2004; Moscicki AB. JAMA. 2001.
HPV Educational Messages (Continued)
• Many women initially positive for high-risk
HPV will not have pre-cancer on further
evaluation or be diagnosed with cancer
• 30% of cervical cancers caused by HPV types
not covered by vaccine
• Women will continue to need cervical cancer
screening even if vaccinated
CDC. HPV Information for Clinicians. 2006.
Resources
• www.asccp.org
• www.arhp.org
• www.cdc.gov
QUESTIONS
References