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 warts, anogenital & oropharyngeal cancers. 4. Role of vaccines in prevention of HPV 4. Describe prevention of HPV through vaccines. 1 11/7/2012 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 2 11/7/2012 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 rela te d 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 3 11/7/2012 HPV & HIV-infection in Men y Men who have sex with men (MSM) are about 17 times more likely to develop anal cancer 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 4 11/7/2012 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 5 11/7/2012 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 Squamous cell carcinoma Penile Source: nih.gov & cancer.gov 6 11/7/2012 Vulvar Cancer Source: cdc.gov HPV-associated vulvar cancer 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 7 11/7/2012 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 cervical cancer 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 8 11/7/2012 Prevention and Education for Vulvar Cancer y Delaying first sexual intercourse until the late teens or older y Avoiding sexual intercourse with multiple partners Vaginal Cancer y Avoiding sexual intercourse with someone who has had many partners y Practicinggg 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 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 9 11/7/2012 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 vag ina y Total hysterectomy y Chemotherapy (topical) y Radiation therapy Source: cancer.org 10 11/7/2012 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.