[Question #1623] HPV multiple strains

46 months ago

Dear Doctors, I will try and keep this brief but it’s complicated. Relevant facts:

  • 38, heterosexual male. Initially diagnosed type 6 and some small warts removed Dec 2012 and a few times in 2013, including December 2013. Given HPV vaccine types 6,11,16 and 18 in Jan 2014.
  • Very sexually active Jul 2012 to Nov 2014 after marriage breakdown (30 plus partners) at which time I met my current partner. Being in a new relationship I got tested and was surprised I was positive for (wet swab of penis) types 6,11,39 and 66.
  • I largely then forgot about HPV and was monogamous except for a breakup period in Feb 2016 when I received oral sex. There was one troubling occasion, recently in Oct 2016, when I was in company with CSWs drunk but I don’t recall sexual contact – I hate not remembering this evening fully. Possible but I don’t remember.
  • On Monday I noticed a tiny sand grain like bump on my penis. Same day Dr examined it and thought it was an old treated wart but swabbed me anyway.
  • Today I got the results. It stumped me. Cleared types 11, 39 and 66 but still positive for type 6 and, this I don’t get, positive for a new type 43/44. 
  • I have no idea how I acquired this "new" type or maybe it was there all along? Does this mean I was unfaithful in October 2016? Not sure how this could have happened. Could I have got it from my partner or could it have been dormant before? 
  • I read that if you have "coinfections" of different hpv types it can take more time to clear them all. 

FYI  my partner has had the shot for 6,11,16 and 18 prior to meeting me (not sure when) but she had an abnormal cell pap (I think) back in October 2016 or thereabouts. She was subsequently tested and the doctor told her she was low risk and there was no need for her to attend a hospital (apparently the next stage of testing). Prior to me I think she had 3 sexual partners in 2013/2014.

 

This is probably feelings of guilt, which can be debilitating for me particularly when I have no exact idea what happened in October 2016. I just don't know how this could have happened and would appreciate if you could shed any light on this as she will no doubt ask me. My doctor is currently overseas and uncontactable. When he examined the 1 small bump yesterday he considered it too early to be related to the Oct 2016 event (if there was one!). Another friend in the medical field said it’s unlikely I’ll ever know the origin (but statistically prob my current partner) and forget about it. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Welcome to the forum and thanks for your question.

To be very succinct, my bottom line opinion and advice is to agree with your "friend in the medical field". And to stop getting tested for HPV.

I think the main source of problems here is your repeated tests for HPV. Such tests are not approved by regulatory bodies for use in males, at least in the US (Food and Drug Administration) nor recommended by public health or STD experts, such as CDC, for use except in testing women, especially in conjunction with pap smears. Experts in general agree, as do I, that the results, whether positive or negative at all, and whether they reveal any particular strains, make no difference in judging patients' risk for HPV related problems like cancer or warts, nor in any steps they can or should take in protecting partners. Further, unlike most STDs (new chlamydia, gonorrhea, or HIV, for example), the appearance of a previously undetected HPV type, or even appearance of genital warts or an abnormal pap smear caused by HPV, is never a reliable indicator of a new partnership, i.e. should never be used as a basis to judge whether a regular partner was unfaithful. It's simply almost never possible to know with confidence when and where a particular HPV infection was acquired, and HPV testing or typing doesn't do that.

One main reason for all this is that the tests' performances are not known with certainty. Even the appropriate methods and sites for specimen collection from males are poorly understood. (Dry swab? moist swab? vigorous abrasion, even with sandpaper? one site [like a suspected wart] or several sites on the penis, urethra, scrotum and elsewhere? All these are unknown.) The tests probably have limited sensitivity, especially on dry skin, i.e. any particular test probably misses many infections. And perhaps limited specificity as well, which means that a negative test doesn't exclude the presence of HPV, nor is determination of type necessarily accurate. The most surprising aspect of this, it seems to me, is that you apparently have a physician who believes in HPV testing in men and perhaps recommended it. But this question sort of presents you as a poster child for the problems it can cause. 

So looking just at your most recent test, I don't necessarily trust that you have recently acquired HPV43/44, nor that types 11, 39, and 69 are gone. The only thing I might take home from your HPV typing results is that you have been continuously carrying HPV6, probably acquired before you were immunized 3 years ago. As for what you did or didn't do sexually last October, for all the reasons above, your HPV results don't give a clue.

You refer a couple of times to "the shot" for HPV, i.e. vaccination. I assume you know that it takes at least two and preferably all 3 scheduled doses of vaccine to get full protection. Good idea and congratulations, but make sure you have had or get all doses. Also be aware that the currently available vaccine covers 9 types (the same four as before plus 5 more), broadening the protection especially against cancers caused by HPV. If you're still under 26 years old, you might consider it.

Beyond completing immunization (or revaccinating with the new vaccine), my advice is to stop HPV testing and move on without worry about it. Having HPV, including all the types for which you have tested positive at one time or another, is a normal, expected consequence of being sexually active. As your medical friend:  you'll never know the origins of your HPVs (maybe your current partner but not necessarily) and it doesn't matter; and forget it.

I hope this has been helpful, but I feel free to ask if anything isn't clear.

HHH, MD

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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Oops -- I didn't remember seeing your age when I recommended (re)immunization. You're out of the recommended age. However, if you received fewer than 3 doses of the previous one, you might consider completing the series. Or discuss with your physician. We might disagree on testing, but it seems he likely is knowledgeable about HPV and its prevention.

Also, as an example of the uncertainties discussed above -- especially HPV test sensitivity and specificity -- HPV6 and 11 are so closely related that many experts consider them a single type, often referred to as HPV6/11. And many (most?) HPV test producers characterize them that way. And yet the lab doing your tests reported 6 and 11 both present, and later type 6 only. I think it's fair to assume you have type 6/11 and that the apparent distinction between them in your tests is meaningless. Just as a way of illustrating how confusing and uncertain all this can be!


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46 months ago
Thanks Doctor, that helped me understand how it could have happened and the pointlessness of continued testing in men. Just to clarify a few points and follow up questions if I may:

  • I had all 3 gardasil shots for types 6,11,16 and 18 in between December 2013 and January 2014 post my alleged type 6 infection. Guessing this doesn't change your assessment? 
  • Also, thanks for your follow up point regarding testing and that an indication of type 6 could also be 11. I previously read type 43/44 (the allegedly"new" type I'm concerned about that showed on my test just yesterday together with type 6) is related to types 6 and 11 being "low risk". Could it be that your statement "it's fair to assume you have type 6/11 and that the apparent distinction between them in your tests is meaningless" equally applies to type 43/44? However, as I gather from your response it's pointless trying to determine when/where this infection came from.
  • FYI the test was with a wet spray, swab (no vigorous scrubbing) of different parts of the penis shaft. I think the purpose was to determine if we treat the sand grain size "wart/spot". I know it is a minor medical issue but will I eventually clear the virus, in particular type 6, which seems to have been around for years? I just hope I don't have to keep going back for treatment in years to come as it's only partially covered by insurance and removal is not pleasant! I have an appointment on Friday to deal with the current spot.
Many thanks again for this service. Based in Hong Kong FYI.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
45 months ago
With deep apology, somehow I missed this follow-up comment, almost a month ago.

Your HPV6 infection either had been acquired before you were immunized, or was perhaps acquired early during the vaccine series, e.g. between doses 1 and 2.

I don't know the details of genetic relatedness between HPV types 43 and 44, but grouping them together suggests the situation is similar to HPV 6/11. Most likely you are correct that there is little difference between them.

The specimen collection system you describe sounds good. However, other methods have been used. The most rigorous research studies did more widespread and even more vigorous specimen collection than you had, e.g. using sandpaper or other abrasive methods. The more vigorous the collection method, and the more sites tested (including sites without visible skin abnormality), the more positive results are obtained.

As for going back repeatedly for treatment, it probably will not be necessary -- and for sure isn't needed unless you have recurrence of warts or other skin abnormalities. And that is unlikely to happen.

Apologies again for the long delay. I'll leave this thread open a bit longer in case these comments raise other issues you wouid like to discuss.

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