[Question #5850] HPV detectable/undetectable - short term fluctuations

18 months ago
Hi there, I've asked HPV related questions in the past, answered by Dr. Hook. This is not an anxiety driven question, it's a curiosity/better-safe-than-sorry question. Context: 25 F, tested positive in the past for high risk HPV with mild abnormal pap, very recently tested HPV negative with normal cytology. My concern is potentially transmitting this virus due to possible HPV fluctuations from active to inactive. I recently read a new and reputable medical study that tested women in a large age range in very short-term intervals over a 4 month period. Please read for reference: https://cebp.aacrjournals.org/content/23/1/200#ref-8 It was seen that HPV would repeatedly go in and out of activity for the majority of the women on multiple occasions, every 7-11 days or so. The assumption was a low viral load fluctuating around the detection levels. PCR and Roche Linear Array were used for detection/genotyping. The detection limit for Linear Array is about 10-100 viral copies for each genotype (I think doctor's offices use similar tests in terms of sensitivity but not certain) My 2 questions are this:1) At this point, I think I've accepted HPV never truly clears and is simply controlled by the immune system (fine.), but what does this mean in terms of transmission? If indeed these very frequent yet short-lived detection rates assume a fluctuating viral load, then is this low viral load transmittable even if it can be momentarily detected repeatedly? I'm not a doctor, but I'm assuming that just because a viral load is detectable, that doesn't mean it's transmittable. I know you cant give me a 100% certain answer on this, but given your medical opinion, how likely am I to transmit this virus? I'd rather ask than assume the worst. 2) Assuming my HPV is transmittable at these low levels, would me repeatedly exposing a potential long-term partner put them at risk? ie, repeated exposure to a low viral load every two weeks or so over and over?
18 months ago
-) I know HPV isn't too risky for men when it comes to penile cancer, but I'm concerned about transmitting HPV to a male's oral region, thus putting him at risk for HPV throat cancer (something that has no preventative screening and is on the rise / overtaking cervical cancer rates). -) I know oral HPV transmission (female-->male) isn't as common as genital transmission, so I'm hoping this would be even less likely at my low viral loads even if they are momentarily detectable.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
18 months ago
Welcome back to the forum. I'm not sure how much difference there is between "anxiety driven" and ""better safe than sorry" -- but I'll give it a try. I scanned your two previous discussions with Dr. Hook and agree with all he said.

My first comment responds to "potentially transmitting...due to possible HPV fluctuations from active to inactive." That indeed is a standard concern, and I don't need to read the citation you provide to know fully well that HPV regularly reactivates. One of the main changes in recent knowledge is that this happens more often than once believed. Howwever, it is a problem without solution and, frankly, one that should not be of concern. It applies to every person who ever had HPV, meaning at least 90% of the population. Nothing can be done to predict or prevent it. Most transmissions to partners do not harm them in any way; usually they never know it's there. And the vast majority of infections cause no serious healh problems -- which is true for both high risk and low risk HPV. And when transmission does occur, and becomes clinically apparent (e.g. warts, abnormal pap smear, etc), usually it is not possible to trace it to any particular partner or exposure.

And you also make an insightful comment, that detection of HPV DNA doesn't necessarily mean the infection is transmissible. There are no good data on this. How likely is it that your own HPV infection will reactivate and be transmissible to some partner in the future? No way to know. Probably not very likely, but certainly there is no guarantee.

Any long term partner who is repeatedly exposed at a time of reactivation almost certainly will be infected; or not, because s/he was previously infected with that HPV type (or was vaccinated) and is immune. And if s/he is infected, probably it will never be known; and if it is, it will be equally likely that s/he is experiencing a reactivation of his own past infection, acquired from someone else rather than you. Usually this can never be known.

You've been doing a lot of sophisticated reading, but you're missing the forest among all the trees you are learning about:  Having and transmitting genital HPV, inclouding the highest risk types, is a normal, expected, unavoidable aspect of being sexual. If not immunized, you should be -- it will protect you from 9 of the HPV types that cause 90% of important health problems (not counting those type[s] with which you already have been infected). Also follow standard pap smear guidelines. Then stop worrying about it!  You can't do anything more, and these steps alone will go a long way to preventing serious outcomes in you or any future partners.

Finally, oral cancer:  First, only one of several types of oral cancer is due to HPV, namely squamous cell pharyngeal (throat) cancer. Second, only a single type, HPV16, does it. Third, HPV16 is one of the vaccine preventable types. Fourth, although such cancers have increased in recent years, with a lot of media attention, it remains a relatively uncommon cancer -- much rarer than the cancers that are much more serious health threats like breast, lung, prostate, colon, and so on. So oral HPV and cancers due to HPV really should not be a big concern either.

So I hope you're able to get a pragmatic understanding of these issues and the normality of your personal situation. Most likely your past HPV infection will never again be an issue for you or for your current or future partner(s). Finally, if not yet vaccinated, do it!

Let me know if anything isn't clear.   HHH, MD
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18 months ago
Thank you,
Yes I have been vaccinated (but only after I learned about my initial infection).
I'm very amazed that HPV does go in and out of activity so frequently every few weeks/months. I appreciate your pragmatic answer - I suppose my guilt stems from the fact that a) I don't know if I have strain 16 (I was too scared to genotype and find out since I know it's the most common high risk strain, and b) I know there's a vaccine out there that I can make future partners get - but, to your point, I don't know how reasonable that would be. I would much rather prefer to move on with my life and not have to disclose this to everyone forever - especially since my pap is clear and I did test "negative" for HPV (not that it even holds much value). I'm not afraid of anyone finding out I gave them anything, I'm just sincerally afraid of giving someone oral cancer. :'(

Anyway... thank you again for your words.
18 months ago
Sorry one last question I forgot to get clarification on. Pragmatically, what is your opinion on my latent infection (that could potentially reactivate over and over at low viral loads) infecting a future partner orally - again, i know you can't say for certain but I'm fine with pragmatics. I ask bc i don't think a one or two time exposure at a low viral load is much to worry about, what i do worry about is repeated exposure at low viral loads - as this could potentially prevent the other person's immune system from clearing the virus. Again, I know it's a technical question, but I don't know if this is how viruses work, and I'd rather ask than leave it to my brain (which will almost certainly take me to unreasonable assumptions).
18 months ago
I know you addressed it with the following "Any long term partner who is repeatedly exposed at a time of reactivation almost certainly will be infected; or not, because s/he was previously infected with that HPV type (or was vaccinated) and is immune."

but again I'm asking about my situation in particular, which I assume will be similar to that noted in my linked article, of occasional redetections at low viral loads that last a few days or so. (you answered me in regards to a full blow reactivation, and I'm not sure if occasional/short-lived 5-11 day hpv redetections count as a full blown reactivation and will hold the same transmission risks)
18 months ago
so sorry last add-on (I just want to make sure I'm being clear since I know I can only ask so many follow-ups on here) - When I say "transmission  occasional/short-lived 5-11 day hpv redetections and not full - blown reactivations" I'm also assuming normal cytology as I don't think I'll have an issue with a fluctuating detectability turning into changes in cervical cells (maybe at an older age but not for while I'm young and still have decent immune memory to the virus)
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
18 months ago
I glanced at the study you highlighted. I doubt it is representative. First, any single study rarely tells final truth; the frequent recurrence results reported need confirmation, and to my knowledge that has not happened even though the study is 7 years old (2012). Second, there were only 39 patients. Third and perhaps most important, the patients were highy selected -- women with bacterial vaginosis. The course of HPV in such women likely is not the same as in otherwise healthy women. Those data probably do not apply to your situation.

Otherwise I don't have much more to say except "get over it". Your situation is no different than that of millions of other women -- virtually all those who ever had an abnormal pap smear. Few of them go through their lives worried about HPV, either from the standpoint of personal health impact or transmission. Whatever the truth of the frequency of detectable reactivation, the vast majority of infected persons have no clinically important recurrences (warts, newly abnormal paps) and do not tranmit HPV to their partners. You have no medical or ethical obligation to inform partners of your past HPV infection and I recommend you not do so. It would not protect their health in the slightest, or the health of their subsequent partners. You are not responsible for limiting the spread of HPV.

You're obviously obsessed with this, but I would strongly suggest you take steps to limit that obsession. You might start by ceasing internet review of these issues. If these problems continue to fill your mind and significantly limiting your life -- and your potential romantic relationships -- to the extent they seem to be, professional counseling might help. I suggest it from compassion, not criticism.

Finally, please note the forum does not permit repeated anxiety driven questions by the same users. This being your third about your past HPV infection, it will have to be the last one; future new questions will be deleted without reply and without refund of the posting fee. This policy is designed to reduce temptations to keep paying for questions with obvious answers. Experience shows that continued answers tends to simply prolong such anxieties, when the real answer normally should be professional counseling. Also, such questions have little educational value for other users, one of the forum's main purposes. I trust you will understand.

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