[Question #6525] HPV vaccine

15 months ago
Docs,

Can someone get the HPV vaccine after age 45? It's not FDA approved or licensed in the US for those who exceed this age (correct me if I'm wrong). How hard would it be to convince a doc or gynecologist to give this vaccine?

Here is why I ask:
I'm seeing a man in his mid 60s who's only ever had 3 sexual partners (or so he says but let's not speculate). Anyway, I mentioned that I once had an abnormal pap 7 years ago in my mid 30s and he freaked out a bit. He said he now wants to get vaccinated just to be safe.

I personally don't think it's necessary since it was long ago, but that aside, how difficult would it be for us to try and get him vaccinated at this age?

Can HPV vaccine be given "off-label".  I'm assuming not, I think that's just for very intense situations like cancer treatment or AIDS or what have you. I'm no doc though so I'm not sure.

His main concern is his age. He says he is old and cannot fight off strong strains of hpv. Any words of wisdom on that? With his age in mind, how likely is he to fight terminate this virus should he come into contact with a new strain?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
Welcome to the forum. Thanks for your confidence in our services.

First, there is absolutely no legal or regulatory restriction on who can be vaccinated against HPV. Once any drug or treatment is approved by the FDA, any duly licensed health care provider can prescribe to any patient for any reason. FDA labeling creates the potential for legal challenge or lawsuits in event of an adverse event, and medical insurers or health plans might decice not to provide or reimburse for a drug or treatment, and many physicians would not prescribe anything outide FDA approval limits. But most physcians in the US don't feel constrained by FDA approval. Otherwise there are no restrictions on the use of the HPV vaccine.

Now, should either you or your new (or potential?) partner be vaccinated? Probably not. The frequency of new HPV infections falls dramatically after people pass age 25 (the rationale for the original HPV vaccine approval only up to age 26), and the chance either of you has an active infection is relatively low; and if one of you does, the chance the other will be adversely affected is even lower.

It's true that immune system capabilities wane with aging. However, there is absolutely no evidence of increased risk either to acquire HPV or to have an adverse outcome form it. It's really not a serious consideration here.

Finally, despite his reiatively limited sexual experiences -- i.e. only 3 lifetime partners -- the odds are good he already has had HPV. And the chance your past HPV infection is still active and transmissible is low. So his risk of an HPV problem will not be materially higher from a sexual relationship with you.

Bottom lines:  1) I don't think immuzation is warranted for either of you. 2) But if he insists, it wouldn't be harmful and certainly not illegal -- but could be costly, since insurance may not cover it. But if he were my patient, or if were me personally or a family member of mine, I would not be vaccinated. Still, he could discuss it with his doctor.

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

HHH, MD
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15 months ago
Thanks doc, I passed this info along last night to this man I'm seeing.

 we both have (mostly him) some clarifying questions....

1. "The frequency of new HPV infections falls dramatically after people pass age 25" -- Does this include males as well? It looks like male HPV rates remain constant with age. Does this mean that, because of a weak immune response, they get reinfected over and over? Most men eventually marry as they age or have steady partners, so does this constant rate of infection mean that they are continually getting reinfected from their wives and/or significant others because they do not build immunity? I have heard men do not build natural immunity. Does this not also mean that women are always contagious?

2. "It's true that immune system capabilities wane with aging. However, there is absolutely no evidence of increased risk" -- I understand there is no evidence, I could not find any date either. However, lack of evidence does not necessarily mean it is not a risk, correct? It just means no one has looked into it.
As a professional who has studied the virology and immunology of this for years, what is your personal take, evidence or not? (disclaimer: I will not take your answer  as fact since as you have mentioned there is no direct evidence, others reading this should do the same) Obviously age doesn't do any favors for immunity or cancer risks, but with HPV, how problematic do you guess it might be, if at all?

3. "But if he were my patient, or if were me personally or a family member of mine, I would not be vaccinated" -- you are saying if you were my doctor, you would not vaccinate me (even if I insisted ), right? I already asked Planned Parenthood and they turned me down, but they are different from private doctors. Just wondering, how much is vaccination without insurance coverage? I cannot find this information online.

4. What about women who age or have hormone changes because of menopause or waning immunity. Will they not eventually become contagious? I thought viruses came back with age like shingles. There is some information I've noted about HPV coming back

5. Last, I would like your feedback on this:  A  virologists I've spoken to (albeit online virologist) stated that those testing HPV positive years and years later are "having a re-expression of HPV viral oncogenes from integrated HPV that was once transcriptionally silent" I don't have enough knowledge to what this means exactly. I'm assuming, though, viral oncogenes are not contagious; so these women are testing positive but not contagious. This virologist gave me an article on this if you're curious for the link. https://www.nature.com/articles/srep20847 What do you think?

Thank you, Dr. Handsfield

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
Very good questions. Directly to them:

1) The fall-off in new infections after age 25-30 esults from a combination of the factors you imply:  past infections with immunity to reinfection with the same HPV types) and behavioral ones (less exposure due to less frequent partner change). Obviously these can vary from person to person, which is why FDA's approval age limit was raised from 26 to 45 a couple of years ago. But that change doesn't imply that all persons up to age 45 should be immunized. It also doesn't mean there aren't some people over 45 who would benefit. As for men not developing immunity to HPV, I've never heard of such a thing. I'm pretty sure you misunderstood something you read, or you found a non-scientific source.

2) You're exactly right:  as epidemiologists often put it, absence of evidence isn't evidence of absence (of an outcome, risk, etc). But nearly universal clinical experience suggests that there are few new HPV infections in people your potential partner's age. When newly positive HPV tests appear at that age, it is believed the large majority are reactivation of distant past infections, not newly acquired ones. To the extent immune system competence influences HPV, it almost certainly is not in susceptibility to new infection but relates only to reactivation of longstanding ones. The same is true of most infections and immune impairment. For example, having AIDS doesn't increase the risk someone will catch any infection (colds, influenza, HPV, or whatever); the effect is primarily in severity of those infections, not susceptibility.

3) Clinics, HMOs, etc often have fairly strict policies, and I'm not surprised Planned Parenthood won't do it. (You will appreciate that PP is in a glaring political spotlight these days, likely supporting conservative policies on all sorts of treatments, not only on abortion.) If you or your partner were my patient, I would advise against HPV immunization. But as I've tried to imply, the decision isn't black or white, and if you "insisted" I would happily vaccinate you. There is no downside to immunization in terms of side effects, toxicity, etc -- except perhaps on one's bank account. The 3 dose course of immunization probably costs $500-800 in most settings.

4) No, it is not true that waning immunity -- or anything else -- leads to frequent reactivation of HPV with aging or after menopause. A large majority of all menopausal women have had HPV and a large majority of them never have newly detected HPV.

5) That's technical language for the fact that many (most?) HPV infections are suppressed but not eradicated by the immune system, i.e. viral DNA persists, and that in those persons there is a potential for future reactivation. His or her use of "oncogenes" suggests s/he is thinking primarily of the subset of HPV types that are oncogenic, i.e. cancer causing. But the vast majority of infections even with the cancer causing types do not actually lead to cancer. (Similar to most smokers not getting lung cancer.)

I would say that both you and your partner seem to be more concerned about HPV and its consequences than is necessary. Either of you could have had far more adventuresome sex lives than you did, or several past incidents of HPV diagnosis, and my advice would be the same:  there is no realistic chance that either of you is going to ever have a future HPV problem and that this should not be even a tiny consideration in your plans for romance and a sexual relationship going forward. Even in the slight chance something happens in regard to HPV, almost certainly it would be diagnosed, treated, and cured long before any serious outcome (e.g. cancer) were possible. Please don't let an impersonal bit of DNA with a protein coat, which happened to evolve to exploit human intimacy for its propagation, have such an impact on your life! This really is a big nothing burger!
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15 months ago
Thanks Doctor H. I'm going to let my partner and you finish the rest of this as he has some follow ups. Let me know if this is okay, if not he can continue using another purchased question.

Some clarifications on your clarifications

1. If you can, I would still would like to know why HPV prevalence doesn't fall in men as they age; it stays constant at all ages

2. Understood and agreed. I would like to know if me catching HPV at this age (66 years old) makes it significantly more likely for me to progress to cancer (specifically throat/oropharynx/back of tongue cancer since these HPV induced cancers are on the rise).
Compared to a younger male, I believe I have a higher chance of HPV developing into cancer because of my old age. Do you think these increased chances for HPV cancer due to age are high or worrisome?  I am in decent health and do not smoke.

3. I understand, thank you for your answer

4. Thank you for your answer

5. I'm sorry, I worded this question poorly. I am no virologist by trade, but I do know a little something about viruses and immunology and had some inquiries regarding transmission of re-detected HPV that I thought I would share with you:
This article: https://www.nature.com/articles/srep20847  gives a possible explanation for the second peak of HPV detection in older women. This explanation could potentially imply no transmission. I found this interesting and wanted to share. Here is a brief quote:

"Our findings offer the first possible scientific explanation for the cause of the second peak of cervical cancer incidence that occurs in older women. As HPV16 could only be detected in these cervices in a disrupted form, the persistence of virus in these samples cannot be attributed to a latent infection as usually defined6. Implicit in the definition of viral latency is the capacity to synthesise new viral progeny. HPV genome integration marks the end of the virus life cycle and the loss of this capacity ... Re-expression in later life of viral oncogenes from transcriptionally silent HPV integrants could explain why the risk of cervical cancer can still continue throughout a woman’s life-time after ... age 60 years in those who appear to have been adequately treated for CIN earlier in life."

If this second peak of HPV positivity could be from integrated HPV re-expressing E6/E7 proteins and/or other "viral oncogenes" from integrated genetic material, then I don't think (maybe/hopefully?) this would imply transmission.  Granted, the sample size is rather small to make any major leaps in assumptions. Either way, this is an intriguing gray area, don't you think? It gives me some peace of mind and hope that not all "reactivations" are transmissible.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
Has there been a misunderstanding from the start? I have believed (or assumed) you're female, based (I guess) on your feminine (?) username and mention of your abnormal pap smear. But quesiton 2 seems to suggest you're also male. I don't think it makes much difference in my replies, however. 

1) Detectable HPV in both men and women DOES fall with aging. I haven't said or implied otherwise. The "second peak" (which may not be real, discussed below) is still a lot lower than HPV detection in younger persons.

2) No. There is no evidence or even suspicion that HPV acquired at older ages is more likely to progress to cancer. Probably not. And although pharyngeal cancer due to HPV is rising in the US, it remains an uncommon cancer compared with others (e.g. prostate, lung, colon, breast, etc) and he would be no more at risk of it with or without a sexual relatioinship with you. I disagree with your statement starting "Compared with a younger male...." It is wrong. And let's say you're right and there's a 50% increased risk? If the risk starts out at 1 chance in a hundred thousand, what does it matter if it doubles to 1 in 50,000. To be frank, these are not rational concerns.

5) This is a single scientific report among hundreds. Many epidemiologists and other experts believe the secondary rise in HPV detection in older women may not even be real, but an artifact of more frequent testing as women get gyn care around the time of menopause. To the extent it's real, it very rarely results in cervical cancer. 

I can't comment on whether or not re-detected (reactivated?) HPV is more or less transmissible. The rarity of new HPV infections in older persons tends to support reduced transmissibility.

That completes the two follow-up exchanges included with each question and so ends this thread. I hope the discussion has been helpful. I especially hope you'll be convinced to drop this entire subject, go with your heart in deciding about your potential new relationship and not your (overactive?) intellect about HPV. 
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