[Question #6372] HPV transmission likelihood

17 months ago
Hi,

Even though I've learned a good bit about HPV transmission from this godsend of a forum, I'd like a more specific piece of insight.

I'm a married man in early middle-age. I regularly see high-end escorts and always use condoms. I always make sure the condom covers as far down the base of my shaft as possible, ensuring so throughout intercourse. Nevertheless, my understanding is that my highest risk is HPV around my groin area.

Before meeting my wife, I had HPV warts frozen off of the shaft of my penis in the early 2010's -- the fruit of some unprotected sexual encounters. My wife tested positive for HPV about a year after we met (early-mid 2010's), but eventually cleared it. Assuming the HPV on my shaft is gone (reasonable assumption?), my  concerns are the likelihood of having and transmitting to my wife any HPV I might have around my groin area. Specifically:

1. How likely am I to have HPV around my groin?
2. How likely is any HPV around my groin to infect my wife? It's my understanding that a gynecological exam involves swabbing the cervix. But since my groin doesn't get anywhere near my wife's cervix, it's not clear to me how HPV would show up on an exam.

One last question, this time about oral herpes -- in the case of no obvious mouth sores, how likely is oral herpes to be transmitted during a brief French kiss? (I've never tested positive for herpes.)

Thanks for your insight.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
17 months ago
Welcome to the forum. Thanks for your confidence in our services, and for your kind words about the forum and what you have learned so far. We appreciate users reading other threads with questions similar to their own.

It's good you're using condoms for your non-marital exposures, and using a "high-end" service, which usually implies pretty low STD risk. But as you seem to know, HPV is always a risk, and you're probably not altering that risk very much, regardless of how you apply and use condoms. Although condoms probably reduce the risk significantly for any single exposure, almost all regular condom users with known HPV infected partners eventually acquire HPV. And exposure only of the groin or upper penis doesn't mean the infection stays there. Probably the virus migrates, either on its own or during the innumerable times all humans manipulate their genitals. For example, women's main exposure is on labia and vaginal opening, but the cervix gets infected; and infection regularly spreads to the anal area, without direct anal exposure. So being exposed only above the condom is no guarantee against active HPV elsewhere on the penis, with potential transmission risk to your wife.

Also, as you likely already know, almost everyone acquires genital area HPV, often several times, and many or most abnormal pap smears are associated with reactivation of longstanding HPV. Your wife's positive test didn't necessarily have anything to do with your previous genital wartrs, but could have been a different HPV strain that either you or she acquired from other partners prior to your relationship. For the same reason, in the event your wife develops yet another anbormal pap smear or positive HPV test, it won't necessarily have anything to do with your non-marital adventures. It is rarely possible to know with certainty when and from whom any particular HPV infection was acquired.

Those comments pretty well cover your specific questions, but to be explicit: 

1) There's at least a fair chance you have been exposed and perhaps infected above the condoms. If so, the HPV isn't necessarily limited to that area but could have migrated to the penis.

2) Therefore, you have to assume there is at least a fair possibility your wife has been exposed and perhaps infected as a consequence of your escort contacts. It's by no means certain. But if it has happened (or happens in the future), she'll probably never know, since the large majority of HPV infections never come to light with either visible abnormalities or abnormal pap smears. If it happens, there will no particular reason to ascribe it to your extramarital exposures.

The chance of HSV1 exposure during any single open mouth (French) kiss undoubtedly is very low in absence of an obvious oral herpes outbreak. Of course it's zero if neither partner ever had oral HSV1 and higher -- but still low -- in presence of known oral HSV1 but no active outbreak. There are no data on which to base a numerical estimate, but I would guess far less than one chance in a thousand for any single kiss.

Final advice:  Given your sexual lifestyle, the overall risk to you (and your wife) is higher for STDs other than HPV and generally more harmful. Your partners probably are at pretty low risk, but not zero; and infections do occur despite consistent condom use -- rarely, but again not zero risk. It would be wise for you to have routine STD testing (gonorrhea, chlamydia, syphilis, HIV) from time to time, such as once a year. You can expect negative results, but better safe than sorry!

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD
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16 months ago
Thank you so much as always Dr. Handsfield for your thoughtful, and most detailed, reply. I've posted questions to this forum before and have indeed learned a lot.

Nevertheless, I had no idea HPV could migrate from one spot on the body to the other! That does clarify why HPV is so pervasive. Still, it is my understanding -- and please correct it if inaccurate -- that HPV transmission is strongly favored by substantial friction and that light touching is far less likely to transmit the virus?

I was also surprised that the large majority of HPV infections in women don't result in visible abnormalities or abnormal pap smears. Could one say that most HPV is no big deal, overall?

To use a slightly crude analogy, it seems HPV is analogous to cockroaches -- you can never get rid of all of them, and if there's even a microscopic crack, they'll find it and squeeze through -- and you might never know it.

Per your testing recommendation, I do get a full panel, usually twice yearly, including HSV1/2 (IgG). All tests have always come back negative. Was there a specific reason you didn't include HSV1/2 in your test list? Terri Warren recommends the "western blot" (is there an eastern one?), but I never see it offered...

Best Regards
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
16 months ago
Think of HPV like an iceberg:  only a few percent are "above the waterline", i.e. cause symptoms or health problems. It's also an iceberg in each individual patient:  the visible or diagnosed infection (wart, abnormal pap) is a minority of the tissues infected. Exactly right that "most HPV is no big deal". I'm not sure I understand the cockroach anaogy, but it's more or less on track.

Once negative for HSV1 and 2, the chance of a new infection without symptoms is low. Repeated testing usually isn't recommended unless symptoms suggest herpes.

"Western" has nothing to do with the compass. Karl Western devised the test. In any case, WB is never recommended except to confirm or refute an uincertain positive result with initial testing. 
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16 months ago
Hi Dr. Handsfield,

I meant the cockroach analogy in the sense that HPV's ability to spread from person to person or from body part to body part is akin to cockroaches' ability to spread throughout a building very easily. Maybe it's not a good analogy. My only point is that HPV spreads easily, just like cockroaches multiply and spread everywhere once they get in.

One last question out of curiosity regarding herpes -- I've read on this forum that the (IgG?) blood test misses 30% of herpes (HSV1?) infections, but that the Western blot still detects these. Is that because of the specific (sub)type of the virus in question, or would repeated IgG blood tests eventually turn up positive?

Thanks again for all your insights.
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
16 months ago
Hi, this is Terri Warren, I answer the herpes questions here so Dr. Handsfield asked if I would chime in your question.
You are correct that the IgG misses 30% of HSV 1 infections compared to the gold standard western blot.  Here is the reference for this statistic. 

Performance of Commercial Enzyme-Linked Immunoassays for Diagnosis of Herpes Simplex Virus-1 and Herpes Simplex Virus-2 Infection in a Clinical Setting.

Agyemang E, Le QA, Warren T, Magaret AS, Selke S, Johnston C, Jerome KR, Wald A.

Sex Transm Disease. 2017 Dec;44(12):763-767

In my experience doing thousands and thousands of antibody tests for herpes, once the test misses an HSV 1 infection (or HSV 2 infection for that matter), it continues to be missed.  Sometimes, if someone tries testing with a different lab that uses a different test brand, it is able to be picked up but certainly not always or even often.  This is due to a lack of sensitivity of the IgG test for HSV 1, it has little to do with the virus we think, more to do with the poor quality of the test. 

I  hope this is helpful for you.  Thank you Dr. Handsfield, for giving me an opportunity to answer this question. 

Terri Warren

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16 months ago
Thank you very much Ms. Warren! Fascinating stuff... 

Feel free to close out the thread. Many thanks.
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
16 months ago
You are most welcome.

Terri
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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
16 months ago
Thanks for weighing in, Terri.

To add a final comment, the fact that Western blot would detect HSV1 despite negative ELISA (IgG test) does not mean WB should be done in most people with negative results and neitehr I nor Terri would recommend you have WB testing. Even in the slight chance you have it, and the infection is genital and not oral, genital HSV1 recurs infrequently and is rarely transmitted sexually to partners. So with rare exceptions, in the absence of symptoms it doesn't matter much.

I hope the discussion has been helpful. Best wishes and stay safe.
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