[Question #1255] HPV transmission

98 months ago

I just read on the CDC site that HPV infections that are subclinical can still be transmitted. What if your infection was several years ago? I thought once they were cleared from your body and you've had a negative HPV test for years, this could not happen. Is this true? What should you tell a partner if you had HPV several years back and have tested negative for years?

H. Hunter Handsfield, MD

98 months ago

Welcome to the forum. Thanks for your question, which goes to the main concern many people have about genital HPV infections.

The terminology about persistent HPV, and HPV clearance, is not standardized. Dormant, latent, persistent, silent, subclinical, etc often are used interchangeably. And the science isn't completley understood. Almost all infections are cleared by the immune system to a point at which they never recur and cannot be transmitted to partners, typically over a few months. HPV DNA may persist, and some experts believe DNA is never cleared entirely. Others believe it is often or usually cleared entirely. Unfortunately, there is no gold standard test to know the truth. If DNA cannot be detected, does that mean it is gone or just not enough to detect? Or that the wrong site was sampled? And if DNA is present, that doesn't necessarily mean there is a potential for reactivation. With these uncertainties, some physicians thus tell their patients that all infections are potentially lifelong. Others tell them the infection is cured as long it can't be transmitted and doesn't reactivate to cause overt disease, such as warts, pre-cancerous lesions, or cancer itself. This is my own interpretation and advice based on the available evidence.

Most likely the CDC use of "subclinical" is intended to mean active infection is present, not just DNA, but that there are no visible warts, no abnormal pap smear, etc. But even these subclinical infections typically are eventually cleared up by the immune system, usually within a few months. Thereafter, they probably cannot be transmitted and do not reactivate. However, late reactivations do sometimes occur, most commonly in the form of an abnormal pap smear. To that extent your statement that "this could not happen" is mistaken. It isn't common, but it happens.

Most experts would agree that there is no medical necessity to inform partners of past HPV infections that have cleared up (e.g. warts gone, pap normal). Some couples of course reveal everything about their past sexual experiences to each other, including past STDs, but this is a relationship issue, not usually one of preventing transmission. In general, informing partners about HPV, especially past infections, does not change their risk of having or getting HPV, or of having complications from it.

The bottom line is that genital HPV should be viewed as a normal, expected consequence of being sexual. Not desirable, of course -- but something that happens to 90% of people has to be considered normal, right? If you are under age 26, you should be vaccinated to prevent infection with 9 of the most common and potentially serious HPV infections (but only types with which you haven't yet been infected). Otherwise, I really don't think you need to worry at all about this.

I hope this has been helpful. Let me know if anything isn't clear. Best wishes--

HHH, MD

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97 months ago

Hello again,

Do you have any scientific data to back up your interpretation that past HPV is most likely not contagious anymore? Morally is it the right thing to do to just leave this in the past and not tell partners anymore? I don't want to risk anyone's health. But I also don't want to feel like a pariah. Also is it worth getting vaccinated in you are in your 40's? Thank you so much.

H. Hunter Handsfield, MD

97 months ago

No, there are not rigorous scientific data. But in the real world, it is rare to see persons with distant past HPV infections whose spouses, years later, show up with new HPV themselves (not counting the spouses who also have other partners).

Whatever the reasons, morally the right thing to do is probably to NOT tell partners. HPV is so common, and mostly so harmless, that informing partners does not reduce their chance of infection, of an adverse health outcome, or help protect their other partners. In other words, sex with you will not affect your partners' health. This would be true even if you had a brand new, active HPV infection. And it certainly is the case for distant past infections.

The chance of new HPV infections is too low after age 26 to recommend routine immunization. That's why the efficacy of the vaccine hasn't been studied in people over that age. Biologically, it probably would work. But it wouldn't have enough personal health or public health benefit to be routinely recommended.

Now, having given you my considered professionl and personal opinion, I have to acknowledge that some experts would not agree with all I have said; and also that as HPV knowledge evolves, new information could dictate a change. But so far this advice has seemed to work well for my patients over the past 30 years and I stand by it.

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H. Hunter Handsfield, MD

97 months ago

Actually, there are indirect scientific data. Among women with newly acquired HPV by cervical or vaginal testing, and who are then tested at 3 month intervals, detectable HPV DNA typically is gone within 6 to 24 months, and does not reappear in the next 1-2 years of ongoing testing. If DNA is undetectable, transmission to partners probably does not occur.

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97 months ago

Does your advice change if I had a LEEP. Does that mean my infection was more dangerous? Why do experts disagree about what the true facts are?

H. Hunter Handsfield, MD

97 months ago

Having had LEEP therapy doesn't change my advice. It suggests you might have had a high risk HPV infection. But that doesn't change anything, since high risk types are the most common anyway.

HPV is a complex issue and research is continuing. I've explained one of the main reason there is disagreement about the natural course of infection; there are legitimate differences among equally qualified experts about how to itnerpret and explain the available data. (See the first main paragraph of my initial reply.) It's a difficult infection to study and understand. However, as I also said above, I stand by the advice and opinions I have given you, whiile remaining open to new information that could become available with future research.

For sure you shouldn't be worried. Almost no women in your situation ever have later recurrences of active infection or transmit HPV to their future partners.

That completes the two follow-up answers included with each question, and so ends this thread. I hope the discussion has been helpful and allows you to move on. Best wishes and good luck.

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