11/7/2012

Conflict of Interest

y Abbott Laboratories What You Should Know About Human y Speaker’s Bureau Papillomavirus (HPV) in HIV-Infection y Boehringer-Ingelheim Robert Dodge, PhD, RN, ANP, AACRN y Speaker’s Bureau Clinical Associate Professor of Medicine University of North Carolina School of Medicine y Gilead Sciences y Speaker’s Bureau

y ViiV Healthcare y Speaker’s Bureau

Learning Objectives Outline 1. Identify the epidemiology and transmission of human papillomavirus (HPV). 1. HPV epidemiology

2. Discuss screening for HPV and management in the HIV- 2. Screening and management of HPV infected population. 3. Correlation of HPV with anogenital & oropharyngeal cancers. 3. Explain correlation between HPV, genital , anogenital & oropharyngeal cancers. 4. Role of in prevention of HPV

4. Describe prevention of HPV through vaccines.

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Incidence and Prevalence of HPV

HPV Epidemiology y Incidence estimated around 5 million genital HPV infections annually in United States. y > 50% of women acquire HPV during first few sexual relationships y Most infections acquired by persons < 30 years old

y Prevalence estimated at > 25 million infected persons.

y Transmission by direct skin - to - skin contact y Compared to HIV and Herpes (HSV) spread during sex

y Approximately 50% of sexually active persons become infected at least once in their lifetime. y 90% of infections cleared by immune system within 1 year

y Infection usually asymptomatic, unrecognized, or subclinical Source: cdc.gov

Types of HPV y DNA virus-double stranded y Over 100 types of HPV exist HPV Prevalence in Women y 40 HPV types that infect genital areas and oral cavity y High-risk HPV types can lead to anogenital cancers y 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68 y Types 16 & 18 (oncogenic) y Account for anogenital and oropharyngeal cancers. y Types 6 & 11 (nononcogenic) y Account for genital warts

Source: cdc.gov

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Prevalence of HPV in Women HPV Prevalence in Women y Prevalence by age groups: y Aged 14-19 years: 35% y Aged 20-29 years: 29% y Aged 30-39 years: 13% y Aged 40-49 years: 11% y Aged 50-65 years: 6.3%

y National Health and Nutrition Examination Survey (NHANES) revealed the overall prevalence for United States females aged 14-59 years is 42.5%.

Source: cdc.gov Source: cdc.gov

HPV Prevalence in Men

y About 1% of sexually active men in the U.S. have genital warts at HPV Prevalence in Men any one time.

y Cancers of the penis, anus and oropharynx are uncommon y only a subse t of these cancers are actuall y relat ed to HPV.

y Each year in the U.S. there are about: y 400 men who get HPV-related cancer of the penis y 1,500 men who get HPV-related cancer of the anus y 5,600 men who get cancers of the oropharynx y many of these cancers are related to tobacco and alcohol use, not HPV.

Source: cdc.gov

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HPV & HIV-infection in Men

y Men who have sex with men (MSM) are about 17 times more likely to develop than men who only have sex with women. Clinical Symptoms y Men with HIV-infection are more likely than other men to & develop anal cancer. Diagnostic Screening and Testing y Men with HIV-infection are also more likely to get severe cases of genital warts that are harder to treat.

Source: cdc.gov

HPV Clinical Symptoms HPV Lesions y Usually asymptomatic y Condyloma acuminata y Keratotic warts y Large or traumatized lesions become ulcerated or infected. y Itching y PiPain y Discharge y Malodor y Urethral Lesions y Altered urine stream y Rarely obstruction Source: cdc.gov

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HPV Lesions What are these lesions? y Papular warts y Flat warts

y Secondary Syphilis Lesions: condyloma latum

Physical Examination Laboratory Diagnosis y Examination reveals four varieties of warts: y Pap stain of cytology specimens from cervix or anus

y Condylomata acuminata: typical cauliflower appearance

y Keratotic warts: horny appearance-often cauliflower appearance

y Papular warts: smooth surfaces

y Flat warts: macular-faintly raised y Visualized with 3% acetic acid

Source: cdc.gov

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Recommendations for Screening Screening for Anogenital HPV y Initial cervical Pap smear performed when first diagnosed or present y Conventional cytology for care for HIV-infection y Detects dysplasia y Repeat 6 months y Cannot be used to test for HPV DNA y After two (2) consecutive normal Pap smears y Conduct annually y Liquid cytology y Detects dysplasia y No national guidelines for anal cancer screening y Allows for reflex HPV DNA y Experts recommend anal Pap smear and digital anal examination as initial evaluation then annual y Repeat in 6 months y Two (2) consecutive normal anal Pap smears y Conduct annually

Source: HRSA-Guide for HIV/AIDS Clinical Care

Grading Pap Smear Results

Normal Negative for intraepithelial lesion or Anogenital Cancers malignancy ASC-US Atypical squamous cells of undetermined significance Vulvar ASC-H Atypical squamous cells- can not excluded HSIL VlVaginal LSIL Low-grade squamous intraepithelial lesion HSIL High-grade squamous intraepithelial lesion Cervical AGUS Other-atypical glandular cells of undetermined significant Anal SCC Penile

Source: nih.gov & cancer.gov

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Vulvar Cancer

Source: cdc.gov

HPV-associated rates by race and Vulvar Cancer Epidemiology ethnicity, United States, 1998–2003 y Vulvar cancers are rare. y It is estimated that almost 2,300 new cases of HPV-associated vulvar cancers are diagnosed in the United States each year. y More white women get vulvar cancer than women of other races or ethnicities. y In general, HPV is thought to be responsible for about 40% of vulvar cancers.

Source: cdc.gov Source: cdc.gov

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Risk Factors for Vulvar Cancer Vulvar Cancer Clinical Symptoms y HIV-Infection y Itching, burning, or bleeding y HPV y Smoking y Color changes on the skin of the vulva y History of y Age y Erythematous or pale y 50% of invasive vulvar cancer occurs in women over age 70 y Less than 20% of cases are in women younger than age 50 y y Vulvar intraepithelial neoplasia (VIN) Skin changes on the vulva y Pre-cancerous changes that may last for several years occur first y Including a rash or warts y Lichen sclerosus et atrophicus (LSA) y Vulvar skin becomes very thin and itchy. y About 4% of women having LSA later develop vulvar cancer. y Sores, lumps, or ulcers y Melanoma or atypical moles y Having melanoma or dysplastic nevi (atypical moles) elsewhere on the body increases risk of developing melanoma on the vulva. y Pain in the pelvis y A family history of melanoma also leads to an increased risk. y Especially on urination or during sex Source: American Cancer Society Source: cdc.gov

Vulvar Cancer Clinical Manifestation Management of Vulvar Cancer

y Surgery: y Laser surgery y Excision y Vulvectomy

y Radiation therapy

y Chemotherapy

Source: cancer.gov

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Prevention and Education for Vulvar Cancer

y Delaying first sexual intercourse until the late teens or older y Avoiding sexual intercourse with multiple partners y Avoiding sexual intercourse with someone who has had many partners y Practicinggg safe sex, including condom use y Quit smoking y y approved to prevent vaginal cancer. y Annual physical examination y STI screening y Pelvic exam with Pap smear Source: cancer.net

HPV-associated vaginal cancer rates by race and Vaginal Cancer Epidemiology ethnicity, United States, 1998–2003 y Vaginal cancers are rare. y It is estimated that around 600 new cases of HPV-associated vaginal cancers are diagnosed in the United States each year. y More Black and Hispanic women get vaginal cancer than women of other races and ethnicities, similar to cervical cancer. y In general, HPV is thought to be responsible for about 40% of vaginal cancers.

Source: cdc.gov Source: cdc.gov

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Risk Factors for Vaginal Cancer Vaginal Cancer Clinical Symptoms y Age: • Bleeding or discharge not related to menstrual periods y almost half of cases are in women age 70 or older y Exposure to diethylstilbestrol (DES) as a fetus (mother took DES during pregnancy) • Difficult or painful urination y History of cervical cancer • Pain during intercourse y History of cervical precancerous conditions • Pain in the pelvic area y Human papillomavirus (HPV) infection

• y HIV infection Constipation y Vaginal irritation • A mass that can be felt

Source: American Cancer Society Source: cdc.gov y Smoking

Vaginal-Vulvar Cancer Clinical Manifestation Management of Vaginal Cancer y Surgery: y Laser surgery to remove the cancer y LEEP (loop electroexcision procedure) y Local excision to remove the cancer y (()gyPartial) vaginectomy to remove the va gina y Total hysterectomy

y Chemotherapy (topical)

y Radiation therapy

Source: cancer.org

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Prevention and Education of Vaginal Cancer

y Delaying first sexual intercourse until the late teens or older y Avoiding sexual intercourse with multiple partners Cervical Cancer y Avoiding sexual intercourse with someone who has had many partners y Practicing safe sex, including condom use y Quit smoking y Gardasil y approved to prevent vaginal cancer. y Annual physical examination y STI screening

y Pelvic exam with Pap smear Source: cancer.net

HPV-associated cervical cancer rates by race and Cervical Cancer Epidemiology ethnicity, United States, 1998–2003

y It is estimated that about 10,800 new cases of HPV-associated cervical cancers are diagnosed in the United States each year.

y More Black and Hisppganic women get cervical cancer y diagnosed at later stages of the disease than women of other races or ethnicities y possibly because of decreased access to Pap testing or follow-up treatment.

Source: cdc.gov Source: cdc.gov

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Clinical Symptoms of Cervical Cancer Risk Factors for Cervical Cancer y HIV-infection y Vaginal bleeding y CD4 count < 200 y Unusual vaginal discharge y Oral contraceptives y GitlGenital warts: previous or curren t y Pelvic pain y Previous abnormal cervical and/or anal Pap smear y Sexual activity before age 20 y Pain during sexual intercourse. y Multiple sexual partners y Cigarette smoking

Source: HRSA-Guide for HIV/AIDS Clinical Care Source: cdc.gov & cancer.org

Stages of Cervical Cancer Stages of Cervical Cancer

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Case Studies Case Studies y 41y/o WF y 38 y/o BF y 25y/o WF y 53 y/o BF y Pap Smear: y Pap Smear: y Pap Smear: y Pap Smear: y Atypical Squamous Cells of y Atypical Squamous Cells of y Normal y High-Grade Squamous Undetermined Significance Undetermined Significance Intraepithelial Lesion (ASCUS) (ASCUS) (HGSIL) y Clinical Management? y Negative Human Papillomavirus y Human Papillomavirus y Repeat Pap Smear annually y Clinical Management? (HPV) (HPV) Present y y Treatment y Clinical Management? y Clinical Management? y Repeat Pap Smear in 6 Months y Colposcopy

Case Studies

y 35y/o WF

y Pap Smear: y Low-Grade Squamous Intraepithelial Lesion (LGSIL)

y Clinical Management? y Colposcopy

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Colposcopy Procedures

Prevention and Education of Cervical Cancer

Management of Cervical Cancer y Delaying first sexual intercourse until the late teens or older y Surgery y Psychosocial care and support y Radical hysterectomy y Support services y Limiting the number of sex partners y Laparoscopic-vaginal radical hysterectomy y Provision of information to patients and y Surgical management in women with subtotal caregivers y hysterectomy y Communication methods (written, Avoiding sexual intercourse with people who have had many partners y Removal of pelvic lymph nodes audiotape) y Fertilityygy conservation surgery y Avoidinggppyg sexual intercourse with people who are obviously infected with genital warts or show y Radical trachelectomy and pelvic lymph other symptoms node dissection y Medical Management y Cold knife conisation or large loop excision y Antiretroviral therapy y Having safe sex by using condoms will reduce the risk of HPV & HIV -infection. of the transformation zone combined with y ACTG - A5029* pelvic lymph node dissection y CD4 count >350 significantly cleared HPV y Quit Smoking y Non-surgical treatment y Decrease in viral load may also have an y Concurrent chemoradiotherapy effect y Annual physical examination y Adjuvant chemoradiotherapy/radiotherapy y y Brachytherapy STI screening Source: cancer.gov and Chang. M & Cu-Uvin. S HIV Med. 2012; 13(6)* y Pelvic exam with Pap smear Source: cancer.net

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Anal Cancer Epidemiology Anal Cancer y It is estimated that about 1,600 new cases of HPV-associated anal cancers are diagnosed in women in the United States y about 900 are diagnosed in men each year in the United States.

y More white women get anal cancer than women of other races.

y More Black men get anal cancer than men of other races.

y HPV is thought to be responsible for about 90% of anal cancers.

Source: cdc.gov

HPV-associated anal cancer rates by race and ethnicity, United States, 1998–2003 Risk Factors for Anal Dysplasia y HIV-infection y CD4 count < 200 y Receptive anal intercourse (RAI) y HPV infection y Genital warts: previous or current y Immunosuppression y High-grade cervical or vulvar dysplasia y Cigarette smoking y Multiple sexual partners

Source: cdc.gov Source: HRSA-Guide for HIV/AIDS Clinical Care

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Anal Cancer Clinical Symptoms Case Studies y 55 y/o BM y 44 y/o WM y Sometimes there are no signs or symptoms. y Pap Smear: y Pap Smear: y Anal bleeding, pain, itching, or discharge. y Atypical Squamous Cells of y Low-Grade Squamous Undetermined Significance Intraepithelial Lesion y Swollen lymph nodes in the anal or groin area. (ASCUS) (LGSIL) y Human Papillomavirus y Clinical Management? (HPV) Present y Changes in bowel habits or the shape of your stool. y Repeat anal Pap smear in 6 months y Clinical Management? y High Resolution Anoscopy

Source: cdc.gov & cancer.org (HRA)

Case Studies Evaluation of Cytology: Abnormal Anal Pap Smear y All individuals with ASCUS or higher anal dysplasia y 26 y/o BM y 54 y/o WM y Referred for High Resolution Anoscopy (HRA) y Biopsy to grade the lesion y Pap Smear: y Pap Smear: y Normal y Low-Grade Squamous Intraepithelial Lesion (LGSIL) y Clinical Management? y Repeat anal Pap smear annually y Clinical Management? y Repeat anal Pap smear in 6 months

Source: HRSA-Guide for HIV/AIDS Clinical Care

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Prevention & Education for Anal Dysplasia

Management of Anal Dysplasia y Latex or plastic barrier y Focus of treatment is on HSIL y Blocks HPV transmission in area covered y Topical 5-fluorouracil y Condoms use for vaginal, anal, and oral sex y HPV vaccines y Cryotherapy y No data on efficacy of HPV vaccines in preventing anal HPV y Studies ar e und er way. y Infrared coagulation y ACTG -A5298 is a double-blinded, placebo-controlled, phase III trial of the quadrivalent human papillomavirus (qHPV) in HIV-1-infected men to y Shown to be most effective for HSIL in HIV-infected individuals prevent anal HPV infection. y y Laser therapy Patient Education y Avoid having anal sex, douching or using enemas before anal Pap smears. y Surgical excision y Annual physical examination Source: HRSA-Guide to HIV/AIDS Clinical Care Source: HRSA-Guide to HIV/AIDS Clinical Care

Penile Cancer Epidemiology y Penile cancer is another rare cancer. y Estimated that more than 800 new cases of HPV-associated penile cancers are diagnosed in the United States each year.

y More common among Hispanic men than non-Hispanic men. y Uncircumcised

y In general, HPV is thought to be responsible for about 40% of penile cancers.

Source: cdc.gov

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HPV-associated penile cancer rates by race and Penile Cancer Clinical Symptoms ethnicity, United States, 1998–2003

y First signs: y changes in color y skin thickening y Phimosis- foreskin difficult to retract or is constricted

y Later signs: y a growth or sore on the penis y It is usually painless. y In some cases, the sore may be painful and bleed.

Source: cdc.gov Source: cdc.gov

Management of Penile Cancer Prevention and Education of Penile Cancer y Surgery y Circumcision: y Genital hygiene y Partial penectomy: Surgeons try to spare as much of the glans (head) and shaft as possible to keep y Perhaps the most important factor in preventing penile cancer in urinary and sexual function. y Total penectomy: Penile reconstruction surgery using a flap of skin from the forearm to create a new uncircumcised men is good genital hygiene. penis has been done, but the procedure is rare. y Mohs surgery (microscopically-controlled surgery): The surgeon surgically removes a thin layer of skin and looks at it right away under a microscope. This process is repeated until the cells are free of cancer. y Voiding HPV infection y Laser surgery: Light from a laser vaporizes penile cancer cells. y CdCondoms use y y Radiation Therapy Limit sexual partners y Chemotherapy y Smoking cessation y Topical chemotherapy: 5-fluorouracil or 5-FU, is applied as a cream for several weeks. y Systemic chemotherapy: Medicine injected into a vein or given by mouth. y Imiquimod: A drug in a cream form that boosts the body's immune system y Annual physical exam y STI screening Source: cdc.gov & cancer.org Source: American Cancer Society

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Oropharyngeal HPV Epidemiology y It is estimated that more than 1,700 new cases of HPV-associated Oropharyngeal Cancer oropharyngeal cancers are diagnosed in women. y nearly 5,700 are diagnosed in men each year in the United States.

y Black pppgeople get these cancers more often than pppeople of other races and ethnicities. y Non-Hispanics and men get these cancers more often than Hispanics and women.

y Cancers in this area of the body are usually caused by tobacco and alcohol, but recent studies show that about 63% of oropharyngeal cancers are caused by HPV. Source: cdc.gov

HPV-associated oropharyngeal cancer rates by race and Oropharyngeal Cancer Risk Factors ethnicity, United States, 1998–2003 y Tobacco use

y Alcohol use

y Sunlight

y Chronic irritation

y Lack of fruits and vegetables in diet

y Human papillomavirus (HPV) infection

y Males Source: cdc.gov Source: cdc.gov & cancer.org

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Oropharyngeal Cancer Clinical Symptoms Oropharyngeal Cancer Clinical Symptoms y Sore throat or ear pain that doesn't go away y Constant coughing y Pain or trouble swallowing or breathing y Weight loss y Hoarseness or voice changes that last more than 2 weeks y Lump or mass in the neck Source: cdc.gov

Management of Oropharyngeal Cancer Prevention and Education of Oropharyngeal Cancer

y Surgery y Primary tumor resection – y Stopping the use of tobacco products is the most important thing a y Maxillectomy - removal of the tumor, including part or all of the hard palate (roof of the mouth), if bone is involved person can do, even for people who have been smoking for many years. y Glossectomy - removal of the tongue y Mohs' micrographic surgery - removal of the tumor in "slices" to minimize amount of normal tissue removed (may be considered when the cancer involves the lip) y To reduce your risk of lip cancer, reduce your exposure to sunlight and y Laryngectomy - removal of a large tumor of the tongue or oropharynx, which may involve removing other sources of ultraviolent (()gUV) light. the larynx (voice box)

y Neck dissection - if cancer has spread to the lymph nodes in the neck y To reduce your risk of HPV infection, limit the number of sex partners.

y Radiation therapy y Regular dental examinations by a dentist are helpful in finding oral y Chemotherapy cavity cancer and some oropharyngeal cancers at an earlier stage.

y Targeted therapy - drugs that target specific cancer cells Source: cancer.org Source: cancer.net

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Genital Warts Genital Warts Epidemiology y National Health and Nutrition Examination Survey (NHANES) data 1999-2004 y 5.6 % Sexually adults aged 18-59 years self reported history of genital warts

y National Disease and Therapeutic Index (NDTI) suggests that incidence of genital warts is increasing.

Source: cdc.gov

STD Surveillance Network (SSuN)—Genital Warts—Prevalence Among Sexually Transmitted Disease (STD) Clinic Patients by Sex, Genital Warts—Initial Visits to Physicians’ Offices, Sex of Partners, and Site, 2010 United States, 1966–2010

Source: cdc.gov Source: cdc.gov

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Clinical Symptoms of Genital Warts Genital Warts Clinical Symptoms y Lesions usually appear as a small to large bump or group of bumps y Raised or flat y Shaped like a cauliflower y Occur within weeks to months after exposure y One or more growths on the penis, testicles, groin, thighs, or in/around the anus. y Warts may be single, grouped, raised, flat, or cauliflower-shaped. They usually do not hurt. y Warts may appear within weeks or months after sexual contact with an infected person.

Management of Anogenital Warts

Patient-Applied Treatment

Provider-Applied Treatment

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Patient-Applied Treatments Patient-Applied Treatments y Imiquimod 5% cream (Aldara) y Sinecatechins 15% Ointment (Veregen) y Apply three (3) times per week at bedtime y First botanical drug approved for prescription use in the United States y Wash off after 6-10 hours for immunocompetent patients. y Repeat for up to 16 weeks y y Side Effects: It is made from the extract of green tea leaves. o Local irritation but mild y Apply three (3) times per day y Safety in pregnancy unknown y Side Effects: y Podofilox 0.5% solution or gel (Condylox) y Local skin irritation y Apply twice (2) daily for three (3) consecutive days y Followed by four (4) treatment free days y y Repeat weekly up to four (4) cycles Not Evaluated y Side Effects: y Urethral, Intra-vaginal, Cervical, Rectal, Intra-anal o Local irritation common y Patients under 18 years of age y Safety in pregnancy unknown y Treatment beyond 16 weeks Source: cdc.gov Source: cdc.gov

Provider-Applied Treatment Provider-Applied Treatment y Cyrotherapy with liquid nitrogen y Trichloroacetic acid (TCA) or Bichloroacetic 80% - 90% y Apply for approximately 10 -20 seconds y Apply small amount to external y Repeat every 1-2 weeks y Allow to dry-White “Frosting” develops y Side Effects: y Avoid contact with uninvolved tissue o Local irritation y Apply oil based ointment around wart o Ulceration y Repeat weekly as needed y Side Effects: y Podophyllin resin 10-25% in compound tincture of benzoin y Local irritation y Apply small amount to external warts y Ulcerations y Instruct client to wash off in 1- 4 hours y Repeat weekly as needed y Alternative Regimens y Side Effects: y Surgical excision y Local irritation y Laser surgery y Ulceration y Intralesional interferon y Contraindicated in pregnancy Source: cdc.gov Source: cdc.gov

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Prevention & Education for Anogenital Warts y Advise clients: HPV Vaccines y Most HPV infections are subclinical

y Cancer and other complications are rare Gardasil (Quadrivalent HPV) y Most sexually active persons have been infected (Bivalent HPV)

y Condoms may help prevent some infections

Source: cdc.gov

HPV Vaccines General Information y No therapeutic effect on HPV existing diseases or conditions HPV Vaccines Safety y Pain at injection site y HPV vaccines CAN be administered to: y Ice the injection site prior to administration y Lactating women y Clients with minor acute illnesses-such as diarrhea or URI with or without a fever y Fever y Women who have had an equivocal or abnormal Pap smears, + HPV or genital warts y Client s wh o are immunocompromi sed eith er from disease or medi cati on y Dizziness y HPV vaccines should NOT be given to: y Nausea y Clients with a history of immediate hypersensitivity to any vaccine component y Quadrivalent HPV contraindicated for persons with hypersensitivity to yeast y Syncope y Bivalent HPV in prefilled syringes contraindicated for persons with anaphylactic y Client should be sitting or lying down during injection latex allergy y Observe client in seated or lying position for 15 minutes y Clients with moderate to severe acute illnesses. y Pregnant women Source: cdc.gov Source: cdc.gov

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HVP Vaccine: Gardasil Education for HPV Vaccines y Approved June 2006/October 2009

y Importance of receiving all 3 doses of HPV vaccine y HPV quadrivalent

y Vaccinated females still need regular cervical cancer screening- y Targets: HPV types 6, 11, 16, 18 begggginning at age 21 y HPV types cause 90% of genital warts y Protects against anus, vagina & vulvar cancer

y All vaccinated clients should continue to practice abstinence or y Approved for females & males aged 9-26 protective sexual behaviors y Administered intramuscular: 3 dose series y First dose – 0 month y Second dose- 2 months after first dose y Third dose- 6 months after first dose Source: cdc.gov y Shake vial before administration Source: cdc.gov

HPV Vaccine: Cervarix y Approved October 2009 Summary y HPV Bivalent y Targets: HPV types 16 & 18 y HPV types cause 70% of cervical cancers y Approved for females aged 10-25 years y Administered intramuscular: 3 dose series y First dose – 0 month y Second dose- 1 month after first dose y Third dose – 6 months after first dose

Source: cdc.gov

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Comparison of Cervical and Anal Cancer Cervical Cancer Anal Cancer Role of the HIV Nurse Clinician Issues Decreasing Increasing y Client Behavioral Modifications: Prevalence in general population 8.1/100,000 1.6/100,000 y Avoid tobacco use Prevalence in HIV population 5.6/100,000 34.6/100,000 y Avoid alcohol use Median CD4 at diagnosis 287 276 y Condom use Duration of HIV (median) 8.2 years 12.4 years y Limit number of sexual partners HPV Types 16 (50%) & 18 (20%) 16 (66%) & 18 (5%) y Provides Interventions: Median age diagnosis 48 years 60 years y National guidelines Yes No Annual physical examination Palpation useful No Yes y Annual or regular screenings Cytology useful Yes Probably y Cervical and anal Pap smears HPVTesting useful in screening Yes No y Appropriate management of HPV lesions Management Colposcopy High resolution anoscopy y Patient –Applied vs. Provider-Applied Availability of well trained Extensive Limited y Education & Counseling cytologists y Vaccination Treatment: High grade lesions Laser, LEEP Infrared coagulation, excision Source: Darragh and Winkler, Cancer Cytopath 2011; 119:5

References Thank You y cdc.gov: Centers for Disease Control and Prevention y cancer.gov: National Cancer Institute Questions & Answers y cancer.net: American Society of Clinical Cancer y cancer.org: American Cancer Society

y hab.hrsa.gov: Health Resources and Services Administration- HIV/AIDS Program

y nih.gov: National Institutes of Health

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Robert Dodge, PhD, RN, ANP, AACRN Wake County Human Services Clinic A 10 Sunnybrook Road Raleigh, NC 27610

Office: 919-250-3078 Fax: 919-250-4429 Email: [email protected]

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