[Question #169] HPV and Immunosupression

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103 months ago
Over a year ago, I began a relationship with a woman who encouraged me to receive the HPV vaccination before we began vaginal intercourse.  I have since completed the three doses of Gardasil (not Gardisil-9).  However, my girlfriend has recently received Pap smear results which indicate the presence of HPV, however, with no abnormal cellular changes.  Although we understand that HPV is pervasive, and has been referred to as the “common cold” of STIs (as quoted by Dr. Handsfield on ASHA’s podcast), there are pieces to our story which we want to explore before we put our concerns to rest.

First, I am currently taking Remicade (Infliximab), a Tumor Necrosis Factor (TNF) blocker, to treat Crohn’s disease.  It is not clear to us what the additional risks are (relative to HPV) if I am immunosuppressed by Remicade.

Second, my girlfriend was previously married to a man who died of a rare soft tissue sarcoma.  Cancer is a very real part of her life, and extra precaution will always be a part of our relationship. (Note: We are sharing this information in case it is clinically relevant.  If possible, please omit this line when posting this question for others to view on-line)

We have not, and continue to abstain from vaginal intercourse.  However, we have been physically intimate, and now I wonder if our skin-to-skin contact in the past has already caused a high probability of transmission.  Furthermore, I have had vaginal intercourse with two other women in the past.  Although condoms were always used, it is my understanding that condoms are not effective against preventing the transmission of HPV.

In researching this topic, my girlfriend has come across the following information regarding the efficacy of receiving the vaccine while on an immunosuppressant.  The Gardasil information page on "UpToDate" states:

Immunosuppressants: May diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation.

Since I am on Remicade continuously, there is no opportunity to revaccinate after 3 months discontinuation.  Do you have any recommendations regarding revaccinating (i.e. would it be advisable to complete the series again with “Gardasil-9”?)  We had been at a loss as to who best to direct these questions/concerns to as they are fairly specific.  We greatly appreciate your time and consideration.
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Edward W. Hook M.D.
103 months ago

Welcome to our Forum.  I will try to help. Your Imfliximab therapy is immunosuppressive, disproportionately impacting your cellular (as opposed to humoral [antibody]) immune function and thereby putting you at somewhat increased risk for activation of certain kinds of infection (TB, fungal infections) if they are latent in your body.  I expect that your doctor tested for things like TB before starting the infliximab- that is the recommended course of action.  The impact of infliximab on either the course of infection or susceptibility to infection has not been specifically studied but it is logical and likely that your infliximab therapy may:

1. reduce your response to HPV vaccine. Antibody responses to the vaccine can be measured and are largely a research tool but in your case it may be worthwhile for your doctor to investigate whether your response to the vaccine can be measured using a blood test.  If you have not responded, there is a theoretical possibility that additional vaccination, possibly with a higher dose of vaccine, may help you to respond.

2.  Increase your susceptibility to infection.  Condoms will reduce this risk but not completely as you point out.  I do not see or think that abstinence is a necessity. 

3. Do slightly increase your difficulty in eliminating the infection and, conversely, increase your risk for infection. This can be addressed by simply watching for any lesions and having lesions which appear evaluated. 

I hope these comments are helpful and welcome limited follow-up questions.  EWH