[Question #79] HPV Transmission

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104 months ago
Good day doctors,

I saw from the internet that genital HPV is very common and they are mostly spread through sexual intercourse and through some non sexual means. As for the effects on health, there are numerous misleading information from the internet and this makes me very confused. I have read through this topic from other forums explained by you but those are at least 1-2 years back and not sure if they are updated. As such, my purpose of writing to you is to obtain solid, reasoned and assuring information from you.

With regards to transmission:
1. After contracted and infected with genital HPV say the high risk strain in the genital area (i.e. penis, groin), are our hands going to be contracted and infected by the virus since our hands will touch our genital areas during showering? If that is so, isn't the virus going to be passed to our face, eyes, mouth or any part of our body including anus by our hands? If that is the case, isn't it dangerous?

2. What is the risk of transmission if someone share towel with an infected person (no warts but high risk type) once?

3. Can kissing spread HPV? If yes, what is the risk of transmission?

Health Effects and Clearance of Virus:
1. I also understand that 2 most common high risk genital HPV (type 16 and 18) are linked to most cases of cervical cancer and rarely other cancer such as anal, penile cancer. Does that mean for men, they are more of a carrier and rarely poses any problem for them as compared to women? Does it still true for uncircumcised men? If no, does it mean guys have to go for circumcision?

2. I do understand that most genital HPV infection usually cleared by immune system in 1 to 2 years. It may take shorter, longer or stay for life (depend on individual immunity system). Does it mean that if the infection does not get clear in 2 years, it is concluded that the infection will persist and stay for life?  Is it possible the infection can take 5 years or more to clear? Does it also mean the immune system must be super competent in order to clear the virus?

3. Do type 16 and 18 harder to clear as compared to other high risk strains? In case where infection (any high risk type) stay for life, does it mean it will pose health problems such as cancer in future (men and women)?

4. When we say infection get cleared by body immune system, does it actually mean get eradicated or remain dormant? There are many different explanation on this. If remain dormant, does that mean it will come back when we age and cause cancer? Does it also come back when we having flu and fever?

5. You have also mentioned to people in the internet not to worry about oral HPV in your other forums. Does it still valid since the rate of oral cancer due to HPV is rising? Does it also true that oral HPV get cleared by immune system faster than genital HPV? If yes, why is this so?

6. Since there is no approved accurate test for men, how do men know if their infection has been cleared by the immune system (especially the high risk type)?

Last but not least, you have also mention it is a trivial infection. As such,  can I say that HPV is not life threatening or deadly?

Thank you.

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

As a general comment, indeed there is a lot of conficting information on line about HPV. However, you'll find less confusion if you limit your searching to professional websites (e.g. academic institutions, government, health derpartments, and other expert agencies) and those that are professionally moderated. For example, you won't find many discrepancies in HPV information between ASHA, CDC, and Dr. Hook's and my past forums at MedHelp.org. I'll also add that there isn't much important HPV information in the past two years. For example, most of our comments and advice on MedHelp probably have stood the test of time.

To correct one bit of misinformation, there are few "non sexual means" of transmission of the genital HPV types. However, nonsexual transmission is common for HPV types that don't typically favor the genital area, especially HPV1, the main cause of common hand and foot warts. But the ones that predominantly involve the genital tract are transmitted almost exclucively by sexual contact.

To your specific questions:

1) As just implied, particular HPV types more readily infect some body surfaces or tissues than others. HPV can be found on the hands of people with genital infections, especially under the fingernails (from hand-genital contact at toilet, for example). However, the fingers aren't infected, just surface contamination. And the virus rarely doesn't "take" when it contacts the mouth, face, etc. An exception may be inoculation of the mouth and throat, but most oral HPV infections are believed to result from oral sex contact, not auto-inoculation from one's own genital infection. Equally important, when genital HPV types are transmitted to other body sites, they rarely cause any visible disease -- no warts, no cancer, nothing.

2,3) There is no known transmission by indirect contact through shared towels, clothing, utensils, etc. The frequency of HPV is not elevated at all in people who share bathrooms, kitches, and towels for years on end, if they are not also sex partners. Kissing is not known to transmit; if it happens, it's rare.

Second set:

1) Correct: HPV 16 and 18 are more likely to cause cancer and pre-cancerous lesions in women than do genital infections men, although on rare occasions they cause penile cancer. Anal cancer due to HPV is a risk in people who have had receptive anal sex (some women and gay men), and HPV16 (and only that type) sometimes causes throat cancer. But even with the highest risk types, the large majority of infections do not go on to cause cancer.

2-4) Persistent infection: At a biological level, most or all HPV infections may persist indefinitely. That is, HPV DNA persists and has the potential to reactivate. However, in the vast majority of case the immune system clears the active infection, the virus cannot be detected, and it probably cannot be transmitted to partners. This typically occurs in a few months to a couple of years. HPV16 and 18 tend to be cleared more slowly than most other types. Delayed reactivation appears to be rare, but probably accounts for most cancers. There are no known specific triggers for reactivation. As far as known, other infections (influenza etc) or aging itself does not do so. But much isn't known, and future research could change a lot of this.

5) I've never heard that oral HPV is cleared more rapidly than in the genital tract. It is true that throat cancer due to HPV16 is rising, roughly double the frequency compared with 10-20 years ago. However, it's still one of the rarest cancers, withonly a few thousand cases per year in the entire US -- way down the list of cancers compared with lung, colon, breast, and so on. The vast majority of oral HPV16 infections don't progress to cancer.

6) In general men can't know when they have asymptomatic genital HPV infection; as you point out, there are no approved tests. Therefore, if for some reason a guy suspects he has or had had genital HPV has no way to know if it has cleared. However, I don't see that it matters. The large majority of infections clear without causing disease and never cause any health problem, and nothing known that can lower or raise the unlikely chance of a health problem. Also, penile cancer is usually a trivial condition, easily recognized and cured with minor surgery or medical treatment long before it becomes threatening. It's not something anyone should lie around worrying about.

I hope these comments have been helpful. Best wishes--  HHH, MD

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H. Hunter Handsfield, MD
104 months ago
Correction, answer no. 1: "rarely 'takes'", not "rarely doesn't 'take'".---
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104 months ago
Dear Dr. Handsfield,

Thanks for your explanation.

I'm sorry that I did not specify the reason for writing to you in my last message as I am not sure if my name stated in the billing address will be reflected here. As such, I only ask some general questions. Before I give my situation, perhaps you can elaborate certain parts of your answers which I am not so clear about. You may have already answered but perhaps I do not get it. Hope you don't mind.

1. With regards to your answers to question 1, you have mentioned this " fingers aren't infected, just surface contamination".  With this, how are we going to use our hands to dental floss our teeth, brushing of teeth or even taking a fruit to eat since these actions will get in contact with the mouth and virus will get transferred to the oral cavity causing oral HPV? Also what about washing of anus during shower? Does it also get transferred to there? I had also ever seen one of your forums that you mention about washing of hands after toilet and that lower the transmission to zero. Is that your advice where everytime we touches our gential area, we will wash the hands first before touching other areas/genital areas or is this something which we do not need to worry about?

2. What does it mean by "the virus rarely doesn't "take" when it contacts the mouth, face, etc."?

3. You have mentioned that kissing is not known to transmit and if yes, rarely. Do you also mean open mouth kissing? If open mouth kissing yes, what is the risk level? This is an issue where people has been debating about and I would like to hear your views.

4. Is your view still the same that we do not need to worry about oral HPV? Is it true that HPV (regardless oral or genital) get interact with smoking and heavy alcohol drinking can cause adverse disease or health problem?

5. What do you mean by delayed reactivation of HPV?

6. So does HPV 16 and 18 more difficult to clear than other high risk type or there are no difference? Also, is it true that the immune system must be very strong in order to clear the HPV active infection?

Now, I shall give the reason for writing to you and hope you can give me your views:
My girlfriend who I will be marrying soon has been diagnosed with some high risk HPV but I do not know which strains and how many of them she has. I only know that from the test result, HPV 16 and 18 are not detected. Her pap smear is also normal. The doctor has told us it is nothing serious, she can have pregnancy except to go for annual pap smear and don't worry too much. As for myself, the doctor also has been reassuring me that after marriage and get infected from her, I will still be safe (be it the infection stays for life or get cleared), nothing is going to cause complication for me (i.e penile cancer, anal cancer etc) and told me to relax, don't worry and get HPV out of my mind.

So dr handsfield, may I know what is your take home message for me? Can I really relax and get this thing out of my mind and lead happily with my partner as advise by my doctor or I should stop this relationship? Fyi, both me and her has already taken 2 shots of vaccine.

Besides to get your take home message, I will also like to ask a few more things with regards to my situation:

1. Will we keep re-infecting every time we have sex during our marriage life? If yes, will the viral load increase? Also if keep re-infecting, does that mean my immune system will never be able to clear the active infection? This is one of my major concern.

2. Regarding the clearing of infection, does the immune system clear all strains at the same time or it will clear one strain at a time? This is because I do not know why immune system will take a few months to a couple of years to clear them.

3. Since her HPV can still be detected, does that mean I will get infected?

4. I am rather confuse with some comments from your past forums.


"Visible warts removed or resolved on it own (or with treatment) and once abnormal pap become normal, it is increasingly unlikely that the virus can be detected by DNA testing and infectiousness-the ability to transmit HPV to a partner-declines"

In our situation, her pap is normal but yet is detected by the test. So is the above comment still valid?

I'm sorry for giving a long list of questions as I understand I only given 2 follow up questions. So I'm trying to ask everything here.

Thank you.

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H. Hunter Handsfield, MD
104 months ago
The answers to all these questions should be obvious based on my previous reply. You're way overthinking this. HPV is a normal, expected, unavoidable consequence of human sex. Its one type of hundreds of viruses and bacteria that inhabit our bodies and rarely causes important health consequences. You also carry E. coli, staph, strep, Epstein Barr virus (the cause of mono), and the chickenpox virus, all of which are mostly harmless but once in a while cause fatal infections. Do you lose sleep over them? Why HPV? It isn't special just because sex is the usual means of transmission. 

Becuase the answers are obvious, my comments are succinct.

1) I explained why this isn't a risk or reason for concern.
2) "Not take" means infection doesn't occur.
3) Any and all kissing, French or a social peck.
4) See comments above. Only minor interactions between HPV and tobacco or alcohol.
5) Obvious and explained above. Virus undetectable but reappears.
6) The reasons HPV16 and 18 are cleared more slowly aren't known. Having a "strong" or less strong immune system makes no known difference.

"Take home message for me? Can I really relax and get this thing out of my mind?" YES!  "...and lead happily with my partner as advise by my doctor" YES!  "...or I should stop this relationship?" Of course not. That's a very stupid idea. However, if your partner were to ask me, I would advise her to be very careful going forward with this relationship. You are very uptight about it, and my guess is you're going to continue to be obsessed, and you have all the earmarks of someone who is blaming his partner for having a past STD she can't do anything about. So I'm worried about the relationship from her perspective. Sorry if that sounds blunt. In any case, you should have no health concerns whatsoever on account of her HPV.

Final questions:

1,3) People are immune to new infections with the same HPV type they have. You cannot reinfect one another.
2) Probably all at the same time.
4) I don't find those comments confusing or see any conflict with anything I have said in this discussion.

As implied above, you are WAY beyond normal in the level of concern you have about all this. But I do hope these comments will help you move on without worry.

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H. Hunter Handsfield, MD
104 months ago
As you note, you have one more opportunity for follow-up questions. But before you ask, please carefully re-read all that has been said up til now. I won't respond to repeats of the same questions in different words or whose answers are obvious from the comments above.---
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103 months ago
Dear Dr. Handsfield,

Thanks for your feedback.

I agree that I am overly worried. The reason also partly due to family members who will be staying with us. So there are some worries about HPV transmission. Since HPV is a virus, of course there are areas that I am concern of such as:

1. Their way of transmission especially touching our genital during showering or after toilets and after which our hands will get contact with the mouth through dental flossing, holding a fruit to eat, sharing utensils etc. Also other areas involve sharing of washing machine to wash our clothes together, bath towel in contact with family members bath towel while hanging etc

2. Though generally most infections can be cleared, my thoughts are in the event it does not happen in my case, what will happen in future since there is no approved testing in men, has it been cleared etc. So it is something like I will be carrying a silent bomb with me and not sure what complications will I be getting.

It will be good if there are some further assurance or additional information from you with regards to the above. If no, I will still try my best to move on without worry base on your last feedback and my doctor reassurance.

However, I do have some questions that need to seek your clarifications as they are explained differently from my doctor. I am not doubting him but just to seek another opinion from experts like you.

1. You have mentioned kissing (whatever type of kissing) is not known to transmit and if yes, rarely. However, I am inform that kissing can transmit from my doctor. May I know your view?

2. For HPV DNA test, is this kind of test able to test very low levels of HPV? According to my doctor, it is mentioned that as long as HPV is in the body (regardless of dormant or active), the test is able to pick up the presence of the virus. As such, he is not able to advise whether my partner is having active or dormant infection. If that is the case, then how we really go about knowing if the infection is active or dormant? May I know what is your view?

3. In one of your forums which I have also posted in my last question: you have mention once warts is treated and abnormal pap become normal, it is unlikely that the virus is being detected by HPV test and transmission decline. As such, why is it that my partner's HPV still can be detected since her pap smear is normal?

4. Are there any guidelines on the clearance rate? What I mean is that if a person has the infection for perhaps 4 or 5 years, is it conclusive that she or he is not able to clear the infection by the immune system, meaning having it for life?

5. If the virus become dormant or undetected, is it still transmissible?

6. You have mentioned that hand-genital contact is just surface contamination. As such, does washing of hands with water alone sufficient  or there is a need to wash the hands with soap? The advice given to me is washing with water alone is sufficient enough.

7. There is a time where one of my family member unknowingly share bath towel with my partner once  ( but not immediately). May I know what is the risk for her to contract HPV?

8. Advice given by my doctor recently is to lead my usual normal routine life after contracting it and not to worry about the transmission and prevention of HPV? Otherwise, it is too stressful. What is your view?

Perhaps that is all I have. Hope to hear solid and assuring comments from you.

Thank you.

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H. Hunter Handsfield, MD
103 months ago
Transmission of HPV does not occur through the sorts of contacts mentioned. Sex only. As for your own infection(s) not clearing, so what? It makes little or no difference in your health. Even a persistent but active infection is pretty much harmless. 

1) Kissing rarely if ever transmits the genital HPV types. I am unaware of studies concerning the many types of HPV that rarely infect the genital area.
2) The only available tests (DNA detection) are the most senstive known. They miss most dormant infections.
3) It takes months or years for HPV to be cleared. Your partner's HPV test probably will become negative with time.
4) Female genital infections with the low risk genital HPV types are typically cleared within 6-12 months, high-risk (e.g. HPV16 and 18) typically 12-24 months. Presumably the rate is the same in male genital infections, but few data are available.
5) I already said that it is not.
6) There is no proved transmission risk from HPV carried on hands or fingers. Washing with water (or soap and water) can't hurt, but my guess is it makes no difference in transmission risk. It's hard to reduce a risk below zero!
7) HPV has never been known to be transmitted by towels, shared bathrooms, or other nonsexual contact. The household members of people with genital type HPV infection never become infected themselves, despite years of sharing toilets, kitchens, eating utensils, towels, etc.
8) Your doctor is exactly right. 

This entire thread reveals an unhealthy and frankly irrational obsession with HPV, to a clearly abnormal and perhaps harmful level. If it continues to dominate your life as it does, you might consider professional counseling. I suggest it from compassion, not criticism. Good luck.