[Question #1665] HPV - Clearance in men

45 months ago

Hi doctors,

I have genital flat warts on my shaft and I have been worried/stressed about the idea of HPV infection being a lifelong virus, reading lot of material around the subject, I have learnt that most infections clear after a period of time, reading most of your comments looks like you believe it as well. Which I am so happy to hear about.

My panic began when I read a newly published study today that studied the prevalence of HPV in men, study states men who are older have a higher prevalence of HPV than younger men (which according to the study surprised the team who did the study, as women’s prevalence seem to decrease with age – ) this study speculates that this could be a result of men having a lesser/weaker immune response compared to women. Please have a look at this study - (Link to study- http://bit.ly/2kcvH8z)

My question is, from your expertise and knowledge after reading this new article/study, do you think men less likely to clear an HPV infection? Or is it safe to say that men too are most likely to clear the virus over time to a point it won’t be infectious just like women.

I understand HPV prevalence is not HPV persistence, it just that in this article the leader of the study speculates that higher prevalence in older men could be due to weaker immune response and thus not have the same level of viral clearance? Or I am interpreting the information wrong from this study?

Please help me put my mind at ease, I’m hoping to hear some good news.

Regards

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
45 months ago
Welcome to the forum. Thanks for your question.

Also thanks for letting me know about this important study. I was unaware of it. I've read the paper itself, which hasn't yet even been officially published ("published ahead of print", i.e. available online pending journal release). While I haven't yet digested it completely, it is a well done analysis of reliable data by expert investigators. It upends some prior assumptions about the natural course of genital HPV infections in men. The big surprise, as you have discerned yourself, is the high rate of persistence in men up to age 59, which is different than in women (although until now the female data have been assumed to apply to males).

To your specific questions:  The study certainly suggests that men indeed clear their HPV infections less reliably and less completely than women do. Whether the explanation is the immune response to the virus (less effective than in women?) or some other factor is less clear. As the authors of the study point out, men itend to develop less strong antibody responses to HPV (and to the HPV vaccine) than women do. However, serum antibody is one rather simplistic measure of immunity; more sophisticated analyses of the immune response are needed to confirm that explanation.

It's even more speculative to say what these data mean for men's health or that of their partners. My guess is not very much. The rates of HPV related cancers in men remain extremely low, especially in proportion to the number of men who (according to this study) still have detectable penile HPV through their 50s. (Pharngeal cancer due to HPV16 is on the rise, but remains much more rare than other common cancers; and to my knowledge the rates of penile cancer remain stable and low. Anal cancer is increasing in men, but primarily in gay/bi men who also have HIV.) In addition, there is no evidence that older men's sex partners are acquiring their HPV infections in significant numbers. Still, this raises a crucial question:  it's not uncommon for monogamous women in their 30s to 50s to develop abnormal pap smears and/or positive HPV tests. It is generally assumed that this is the result of reactivation of HPV acquired many years previously. The new study suggests that perhaps many of these are in fact newly acquired infections from their male partners, including monogamous husbands.

Presumably your flat warts have been professionally diagnosed. If so, they should be treated -- presumably that is being done, right? If not, why not? In any case, if you have a regular partner, you can safely assume s/he has been repeatedly exposed to your infection and should be on the lookout for warts and get care if anything shows up. But otherwise, nothing need be done -- and there is no point now in modifying your sexual frequency or practices with that person. However, you should inform any new partners of your infection until the warts have cleared up. But there is nothing in this new research that changes this advice.

Like all good research, this study raises more questions than it answers, typically stimulating still more in-depth study. But for now, it should not be viewed as seriously "bad news" in regard to men's health or that of their partners.

I hope this has been helfpul. Let me know if you have further questions or comments.

HHH, MD

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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
45 months ago
Since posting my reply above, I have been in touch with a CDC expert in HPV epidemiology. She reminds me that there have been a couple other studies with similar results, i.e. more persistent HPV in men than women, but they were not population based (i.e. not representative of the US population), as this one was. Another population based report on this, from CDC itself, will soon appear in the scientific literature. So the evidence is building on persistent HPV in men. So the new information seems even more solid than I implied above.

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45 months ago

Thanks for your response. the link I sent was an interview– Please visit this link to the study itself - http://bit.ly/2jbwuoK

New study did NOT follow people for multiple years studying clearance, it only took ONE set of samples of over 1900 people and found men with older ages testing positive. At the end, it states men clear the virus, but because of lower immune response they could be reinjected as the number of sexual partners stayed constant over the ages; urging vaccination – Quote from above study

’Clearance of genital HPV infection in men has been reported to occur between 6 and 18 months, which is comparable to that in female individuals.26 However, male individuals have lower circulating HPV antibodies than female individuals despite a higher genital HPV infection prevalence.27,28 This finding may explain the difference in HPV immune responses between the sexes. The HPV Infection in Men (HIM) cohort study26 reported that the number of partners and new partners in the last 3 months was similar for all age groups, hence potentially providing continued exposure to HPV throughout life in male individuals. Therefore, if men generate a lower and weaker HPV immune response in the setting of remaining at high risk of acquiring new HPV infections throughout their lives, then vaccination programs for older men might be warranted.

Other studies focused on clearance in men over MULTIPLE years, find most men eventually clear the virus as they do in women, one of these studies are referenced in this new study. Please see below studies on clearance in men done over multiple years.

Links

-          http://bit.ly/2k0dJsM

-          http://bit.ly/2juokZx

Is it more reliable to use, studies where clearance itself was studied over course of years in men is more reliable than a single study of samples which didn’t follow over time to see if those tested positive cleared the virus over the years?

I am a male and 25 years of age, nonsmoker, you think from your experience men who haven’t had a wart outbreak in 6-12 months can safely assume they are not infectious anymore? I have tiny white FLAT spots on my penis glands which doctors say is too small to be treated. 2 areas went away but flat white one spot remains.

Please let me know your thoughts.

Thanks

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
45 months ago
As I said above, before I replied above I had looked up and read the research paper itself, including the quote you posted. Both study methods are valid; there is no competition between them. This additional information does not alter comments above.

I cannot judge whether the "tiny white flat spots" you see are flat warts; you'll have to rely on professional examination. If they are active warts, you should assume you have an active HPV infection that could be transmitted to partners. If they are merely altered skin appearance due to previous warts (or unrelated to warts at all), then standard advice until this recent research would have been that you probably are not infectious. Given the recent studies, perhaps that advice will need to be modified in the future. 

But not necessarily. The consistent experience of most experts is that the sex partners of people with distant past warts (or other forms of HPV infection) rarely develop warts or new HPV infections. So it seems that persistence of detectable HPV does not necessarily mean those persons are infectious; they may have HPV DNA alone, without intact or complete virus that can be transmitted. So for now my advice remains the same as it has always been:  within a few months after warts have cleared, you can safely assume active HPV infection is gone (even if viral DNA is still detectable) and there is no need to take precautions with future partner or even to inform them of the past diagnosis of warts.

Bottom line for you:  See a dermatologist for advice about whether the spots you see are persistent warts and advice about treatment if necessary. If s/he believes they are not warts, go on with your life (sexual and otherwise) on the assumption you no longer are infectious for partners.

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44 months ago

Thanks doctor! there is reason to doubt my diagnosis of warts.

I am UNCIRCUMCISED, didn’t clean inside my foreskin before diagnosis,I often got painful itching and a smelly substance back then. it goes away and the itching stops. before my diagnosis I've never seen the inside of my foreskin for 22 years.  not cleaning, could it have caused infections that altered the appearance of my glans? (Comments?)

I’ve only been with one girl. I was only with her for a week. Slept 4 times; once with a condom, 3 without.  I remember she did have abnormal bleeding after sex (is it a sign of HPV for a 23 year old women?). After sleeping with her a couple of weeks later, I did get the usual itching again and w
hen I pulled back my skin then  4 weeks later - I realised I had what looked like flat smegma stuck on the glans (no itching) it wouldn't go away with washing.  (is it common to get warts from 4 times of unprotecred exposure? Study among couples says 20% chance of transmitting over 6 months? Is it common for warts to appear within 4 weeks)


my doctor's in srilanka who I doubt is that experienced; initially misdiagnosed as herpes and then said it wasn’t herpes and was warts. I used aldara and the white patches pealed away with the rest of the skin as it destroyed my skin upon application.

Doctors in UK who saw my spots doubted my spots being warts as they were not growths or anything like a skin tag and were inside the glance, barely overt. appeared like a white cloud inside the glance. 

It's been two and half years; I still keep getting these spots (suspected warts) mostly inside the glans skin barely above the glans skin (is this the norm?). They appear and disappear over a few weeks (Is this common for warts?). Except for two spots which have been continuous barely above the skin; have been treated for with aldara, acid and liquid nitrogen but these spots seems non responsive. (if its a wart shouldnt it respond?)

If you think its warts, I don’t worry about the biology, on the practical side of the virus. I will follow your advice on waiting 6 months of clear no symptoms to indicate most likely I am no infectious?.I hope to get married soon so I dont want to infect my future wife. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
Based on both your sexual history and more detailed description of your penis, genital warts are very unlikely. Warts never come and go over a few weeks. And failure to clear up after treatment with both imiquimod (Aldara) and liquid nitrogen also indicates something other than warts. My guess is that you are seeing normal variations in your penile skin.

My advice is that you find a single doctor you trust, preferably a dermatologist. I'm sure s/he will affirm you do not have warts and probably nothing to worry about. In the meantime, stop all attempts at treatment -- which not only might help but might be harmful, and for sure will make it more difficult for a doctor to make an accurate diagnosis. 

That completes the two follow-up comments and replies included with each question, and so ends this thread. I hope the discussion has been helpful. Do your best to go forward without further worry about genital warts or HPV.


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