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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