gardasil / treatment of warts / beneficial?


hiya Bob,

My HIV+ boyfriend is currently suffering from anal warts (perianal and inside the anus). So far the doctors have advised to use zink-supplements and they planned to cauterise the internal and external warts. I'm wondering if gardasil might be able to offer not only prevention, but also some support in treating genital warts. i'm a biochemist myself, and am certainly in favor of tackling this problem as holistically and completely as possible. I know current indications for the vaccine over here (europe) are in the prevention of cervix cancer, but i came across some data that the FDA is testing (has tested?) the vaccine in the context of warts/ men, both treatment and prevention. What are your thoughts on this? Should we "invest" in the treatment (not that expensive over here)?




The HPV vaccine Gardasil has been evaluated in boys/men and found to be effective. (See below.) The question is whether vaccination would help someone already infected with HPV/genital warts. The vaccine was designed to be a preventative rather than therapeutic agent. It offers protection against certain strains of HPV that are known to induce cancers. The answer to your question is no one really knows. The general consensus is that the vaccine would probably not be helpful in this situation. One consideration would be for you to be vaccinated with Gardasil, hopefully to prevent acquiring HPV from your boyfriend.

Dr. Bob

HPV vaccine for (adult) men? Dec 22, 2009

Dear Dr,

I'm HIV+ undetectable 43 y/o man. I understand having anal sex (sometimes unprotected), especially as the receptive partner, puts me in high risk for HPV. However, on my last HPV swab I tested NEG (!!). Though there are no guidelines for males in my age group - would getting the Gardasil vaccine (off-label) be a wise thing to do since I'm HPV-? Thank you very much!

Response from Dr. Frascino


As you may know, Gardasil was initially approved for use in girls and young women ages 9 through 26 for the prevention of cervical, vulvar and vaginal cancer caused by human papilloma virus (HPV) types 16 and 18; precancerous lesions caused by types 6, 11, 16, and 18; and genital warts caused by types 6 and 11.

In October of this year, the FDA approved Gardasil for the prevention of genital warts caused by HPV types 6 and 11 in boys and young men, ages 9 through 26.

Gay and bisexual men are 17 times more likely to develop HPV-related anal cancer than heterosexual men, according to the CDC. The virus has also been linked to genital warts and to cancers of the mouth, head, neck and penis. Studies are still ongoing to assess Gardasil's efficacy and safety in HIVers and in folks older than 26 years. Would the vaccine protect you? Unfortunately, we do not know! There is no a priori reason why the vaccine would not produce the desired protective anti-HIV antibodies, but we have no scientific proof yet. It is possible to get Gardasil off-label from some HIV specialists. Its fairly pricey and requires three injections over a six-month period.

Stay tuned to The Body. We'll keep you informed as more information becomes available. I'll reprint below some information from the archives.

One final note. What was that comment, "sometimes unprotected," all about??? Barebacking is dangerous whether you are positively charged or not! Not only do you risk transmitting the virus to your partners (an unconscionable thought!), but you also put yourself at risk for other STDs, including superinfection with another strain of HIV, that could seriously compromise your health. If you're not going to cover your rocket, keep it in your pocket!

Happy Holidays.

Dr. Bob

Gardasil Jun 4, 2007

I read your posting for May 11 regarding this.

What are the factors you consider as to whether men (particularly healthy, HIV+ men) should get Gardasil treatment?

I just received my first shot the other day, and intend to finish the last 2 (2 months, then 6 months).

I do not see the downside of being immunized against this.

Can you please clarify, etc.

Thank you.

Response from Dr. Frascino


There are two potential downsides that immediately come to mind:

  1. Cost. These are very expensive vaccines.

  2. Safety and efficacy clinical trials of the vaccine in men have not been completed. A study is underway in gay men to determine if Gardasil will protect them from certain types of cancer.

As you are undoubtedly aware, the vaccine is approved (so far) only for girls 9 to 26 years of age. The CDC recommends routine vaccination for girls 11 to 12 years of age, before they become sexually active. A number of gay men, both HIV positive and negative, are lining up to get vaccinated; however, at this point there are no specific guidelines or recommendations to follow as Gardasil has not yet been approved for use in men. Stay tuned; I'll keep you posted as this story unfolds.

Dr. Bob

Gardasil (HPV) vaccine for those already with HPV (HPV Vaccine for MEN) (GARDASIL) VACCINE (HPV) Dec 3, 2007

I'm a 43 year old man with HPV already, awaiting biopsy results to see if I have anal cancer as we speak. Is it a waist of time and resources to get the Gardasil (HPV) vaccine at this time, or will it help down the road whether I have anal cancer, have to go through radiation and chemotherapy, or not?

Response from Dr. Frascino


Gardasil is a preventative, not a therapeutic vaccine. Consequently if you already have the HPV strains contained within the vaccine, getting inoculated will not provide any help. I'll reprint some information about Gardasil from the archives below.

Good luck!

Dr. Bob

VACCINE (HPV) (HPV Vaccine for MEN) (GARDASIL) Oct 26, 2007

I am man, 43 y.o. and HIV+. May I take the human papillomavirus (HPV) vaccine?

Response from Dr. Frascino


There are no specific contraindications to getting the Gardasil (HPV) vaccine for those who are HIV infected. However, what we don't know for certain just yet is whether or not it is equally effective in HIVers compared to the HIV-negative kids and young adults who received the vaccine in clinical trials and for whom the vaccine is now approved and recommended. Certainly there are a number of HIVers (as well as HIV-negative gay men) who have opted to get vaccinated based on the limited information we have so far. Clinical trials in men, both HIV+ and HIV-, are underway. The vaccine is not cheap, but it appears to be extremely well tolerated and very effective. I'll reprint below for our readers some general information about HPV, including some information about the vaccine.

Good luck!

Dr. Bob

HPV Vaccine for Men (HPV) (GARDASIL FOR MEN) Aug 14, 2007

Are there any recommendations for men (esp poz gay men) to get the HPV vaccine?

Response from Dr. Frascino


There are no formal recommendations yet; however, some guys are already getting vaccinated. (See below.) Clinical trials are underway to evaluate efficacy and safety of using Gardasil in men. I'll reprint some information from the archives below. I would recommend, as a first step, you get an anal pap smear to ascertain if you have active HPV and if so what subtypes. Then talk to your HIV specialist to ascertain if the HPV vaccine is something you should consider, even if the formal recommendations are still pending.

Dr. Bob

Gardasil Follow-Up Jun 22, 2007

Hi Dr. Frascino,

I noticed a post recently about Gardasil, and I had a follow-up question. I realize that there is some debate about whether gay men should get this vaccine, but isn't it true that the vaccine would only help those not already infected with HPV? I have read that some 80% of HIV+ gay men are also infected with HPV. (I have no idea whether this statistic is accurate.) So wouldn't I have to first be tested for the presence of HPV before considering whether to get these injections? It sounds like the vaccine would be a waste of time and money if I already have HPV. Or does this vaccine have therapeutic properties as well in those already infected? Basically I'm just confused about this whole thing and am looking for someone to clear all this up for me.

Many thanks.

P.S. Your line in another post about Dubya not knowing when to pull out made me laugh out loud.

Response from Dr. Frascino


As it turns out, there are many variants of HPV, but only a few are associated with the subsequent development of cancer. The key question is whether vaccinating someone who may have been exposed to HPV, but not to the specific variants the vaccine is intended to prevent, will be effective. Time will tell. Stay tuned. We'll keep you posted as this story evolves.

Dr. Bob

Doctors Urge HPV Vaccine for Men and Women

July 31, 2006

Eventually, men, women, girls and boys should be universally vaccinated against the STD human papillomavirus (HPV), regardless of their individual risk factors, two doctors argue in a new article. In June, the Food and Drug Administration approved Merck & Co., Inc.'s HPV vaccine Gardasil for girls and women ages 9-26. A month ago, a government advisory panel recommended routine vaccination of girls ages 11-12; and girls and women 13-26 who have not been vaccinated, have had an abnormal Pap smear, genital warts or other specified conditions.

About half of sexually active adults contract HPV at some point. HPV is usually harmless, though it can lead to cell abnormalities in the cervical lining that can progress to cancer. It can also cause genital warts and penile cancer. Gardasil protects against four types of HPV that can lead to cervical cancer and genital warts. "We need to move toward a paradigm where this is a universal vaccine," said co-author Dr. Bradley Monk, a University of California-Irvine associate professor in gynecologic oncology. Because males can transmit HPV to their sexual partners, it is sensible to vaccinate boys, he said.

Some groups oppose the idea of vaccination as a requirement for school admission, saying parents should decide whether children receive an STD vaccine.

Monk dismissed the argument that an STD vaccine could encourage promiscuity. "Just because you wear a seat belt, does that mean you drive recklessly? Or just because you give your son a tetanus shot, does that mean he is going to go out and step on a rusty nail? Of course not," he said. "To have a vaccine that prevents cancer and not use it would be one of the greatest tragedies."

The full commentary, "Will Widespread Human Papillomavirus Prophylactic Vaccination Change Sexual Practices of Adolescent and Young Adult Women in America?" will be published in the Aug. 1 issue of Obstetrics & Gynecology (2006;108(2)).

HPV Vaccine: In London, Men Demand -- And Get -- Equal Treatment Since it was approved last year, the buzz has grown louder over the human papillomavirus (HPV) vaccine, which can protect women from the four strains of HPV that together cause 70 percent of all cervical cancers. But as the world debates whether HPV vaccination should be mandatory for young women and girls, another question looms: What about men? After all, HPV can cause anal cancer, and may also be a cause of penile cancer. That's why dozens of gay men in London have requested -- and received -- the vaccine, in spite of the fact that the United Kingdom's government hasn't approved it for men to use. The Freedomhealth clinic in London started offering HPV vaccination to gay men in January and now vaccinates about 10 people a week, even though some experts have called for more research before offering the vaccine to men. (Web highlight from The Advocate)

What about vaccinating boys?

We do not yet know if the vaccine is effective in boys or men. It is possible that vaccinating males will have health benefits for them by preventing genital warts and rare cancers, such as penile and anal cancer. It is also possible that vaccinating boys/men will have indirect health benefits for girls/women. Studies are now being done to find out if the vaccine works to prevent HPV infection and disease in males. When more information is available, this vaccine may be licensed and recommended for boys/men as well.

HPV Vaccine Jun 10, 2007

Why are folks at my church so concerned about the HPV vaccine?

Response from Dr. Frascino


Good question!!! Actually, I really don't quite understand exactly what it is that some parents don't understand about Gardasil, the HPV vaccine licensed last year to help prevent most cases of genital warts and cervical cancer!

The facts are quite clear:

  1. HPV (human papillomavirus) disease is the most common sexually transmitted disease.

  2. There is no treatment for HPV infection.

  3. HPV can cause cervical cancer. (Seventy percent of cervical cancers are caused by two variants of HPV. The HPV vaccine protects against these two variants.)

  4. Most people infected with HPV do not know they are infected, yet can transmit the virus to unsuspecting sexual partners.

  5. Twenty percent of American girls 14 to 19 years of age are already infected with HPV.

  6. The vaccine only works if administered before the women become infected by the viral variants covered by the vaccine.

So what about the objections being raised by some parents:

The most egregious is the ridiculous notion that immunizing young girls against HPV will encourage promiscuity. This is another fallacy proposed by the misguided "abstinence-only" folks. It has been scientifically shown that the abstinence-only message is rarely, if ever, effective. Half of American girls become sexually active before graduating from high school. Even if this weren't the case, why would a vaccine make girls sexually indulgent? Even rudimentary sex education knowledge would advise that HPV is only one of many potential STDs, and certainly not protective against unwanted pregnancy!

The backlash against HPV vaccines is yet another harmful side effect of Dubya's "faith-based science" mythology.

Is it 2008 yet?

Dr. Bob

HPV vaccine and cervical/oral cancer? Jul 5, 2007

Hello Dr. Bob. This is the Mommy that you have always been so kind in easing the worries of, needing your wisdom once again in an extremely uncomfortable situation . I hope that these questions find you in the best of health, and as always, I thank you from the bottom of my heart for your reply. I was diagnosed with HPV-16 which seems to be the cause of my cervical cancer. I am trying to find the words to ask you the following questions as they are extremely embarrassing for me, but I am desperate for your help in explaining the answers and you are the only person I trust to ask. OK. When my husband and I have engaged in sexual relations, sometimes when we are in the "spoon" position, his penis slips into my anus while trying to, from the back, put it in my vagina. I wonder if because of this, I now have... How I absolutely hate to say it... warts... I cannot stand it Dr. Bob! It is not enough that I feel so filthy and dirty with HIV, but to now have this... I have tried and actually have cut our sexual intimacy to where it is almost non existant especially now that I have this situation that has put him at even greater risk (the condom has broken sometimes (he says they are too tight despite the fact that he is not really large) as well as having the condom slip off) and yes, I know he has to get tested but the guilt that I feel... There are no words Dr. Bob to express the profound guilt that I feel... The utter disgust... My husband is not bothered by this at all, as he says he knew there would be risks but that he is willing to take that chance. I am the one that is having serious issues. The warts had been removed months ago in what is such a barbaric way, shots in and out of the anus that hurt so bad, and then a burning tool used to burn them off only to have them come back. I hate that when I bathe (which I do at least 3-5 times a day out of how filthy I feel) I feel them and they itch no matter how I scrub. I researched online to see what remedies may be used to get rid of them and although alot of them where outrageous, I am so desperate (not to mention that I do not want to go through that procedure again) that I am tempted to try anything in hopes of feeling a little "normal". Is there anything in the works as far as a vaccine or anything else for people that are in their 40s and already have HPV? Is there anything that you can recommend I take to get rid of them? I know there is a cream that sounds like a blessing, but I have three disabled people in my family and we are on such a tight budget I cannot afford it not to mention that I do not have insurance. Also, to add to my guilt even more, we used to engage in oral sex as well, and now I am even more petrified because I read that HPV-16 can also cause Oropharyngeal Cancer! What are the probabilities that he has contracted any or both (via penis and/or mouth)? Should I examine his neck,throat and penis frequently and if so, what should I look for? Is it a given that he already has contracted either of them? I cannot sleep at all and am looking so physically ill (everyone is commenting on it) and I pray there is a ray of hope to all of this. I have an undetectable viral load (except for a small blip on two occasions which the Dr. says is nothing to worry about) and my T-CELL count is above 600. Do you think that I may be able to enjoy having sexual relations again? How does someone with these situations even consider having sex? This is driving my husband nuts because he desperately misses our intimacy and even when I try to engage in it with him, I find myself cringing and becoming stiff when he touches me in my frontal area because I am afraid his fingers or otherwise will find their way to my anal area and, I do not have to tell you because I am sure you already know, it is an absolute kill joy. Thank you for reading this and for your reply which I anxiously await. You are, as I have mentioned numerous times before, an incredible human being. You are very much loved and appreciated. Wishing you a great evening.

Response from Dr. Frascino


I'll post some general information from the archives about HPV below. This will answer some of your questions.

As for your husband's problems with condoms, I suggest he try different varieties until he finds the best fit. It's a bit counterintuitive to complain the condom is "too tight" only to have it "slip off!"

Next, regarding treatment of HPV, I would strongly recommend against the online remedies. Not only don't they work, they are often expensive and may even be harmful. Unfortunately, there is no therapeutic vaccine available yet. As for "getting rid of them," you'll need to work closely with a doctor you trust. There are a variety of treatments available and with persistence you should be able to clear up the active warts. Hopefully, with your improved immune status you'll be able to mount your own immune response against the warts. It is true that being HIV positive can make it easier for genital warts to grow and harder to treat them, but they are indeed treatable.

Should you examine your husband for HPV symptoms? No, you wouldn't know what to look for. His physician can examine him periodically as indicated.

Finally, your guilt and psychological reaction to having contracted several STDs (HIV and HPV) is excessive. These are viruses and all humans are susceptible to them! Bathing three-five times a day because you feel "filthy" is indicative of an abnormal psychological reaction to being infected. Talk to your doctors to see if there are counseling services available that may help you and your husband reestablish intimacy safely and with confidence. Illness should never induce shame!

Good luck. Stop being so hard on yourself!

Dr. Bob

hiv and hpv May 20, 2007

My path report showed CIN-I and HPV. Does this mean I am positive for HIV?

Response from Dr. Frascino


No, HPV (Human Papilloma Virus) and HIV (Human Immunodeficiency Virus) are two very distinct viruses. Testing positive for one does not automatically mean you are positive for the other. CiN-1 stands for cervical intraepithelial neoplasia stage 1. This condition can be cause by several strains of HPV. It will require follow-up with your gynecologist. If you've placed yourself at risk for HIV (unprotected sex, sharing IV drug paraphernalia, etc.), you'll need a specific HIV test three months or more after your last potential exposure. You can read much more about HPV and HIV in the archives. I'll reprint some information about HPV below.

Good luck.

Dr. Bob

HPV and HIV May 17, 2006

Hello, My boyfriend has HIV and I do not. We have protected vaginal sex daily and he performs oral sex on me regularly. I also perform oral sex on him, but only for a few minutes, and never to the point of ejaculation. We have also engaged in some light rimming. He has a good Infectious Disease Specialist. I get tested regularly for HIV.

Recently, after seeing a commercial on television that talked about the correlation between HPV and cervical cancer, he mentioned that his last two girlfriends (they were before he knew he had HIV, and they had unprotected sex) had abnormal cells that were scraped off/frozen from their cervices (sp?). Anyway, this kinda freaked me out. I have never noticed any lesions on him. He can't go in for an examination yet, because his health insurance is not in effect yet.

I have not noticed any lesions on myself, but thanks to our public school system sex education, we don't have any information on HPV. Thank God for that commercial.

  1. Can we still have oral sex? 2) Can he be tested for HPV? 3) If I have it, will I have an outbreak? 4) Does this disease go away or will he/we have it for the rest of his/our lives? 5) If I have the cancerous type, and the abnormal cells are removed, am I contagious to him for reinfection? 6) Is [male condom] protected sex good enough if we don't see any lesions?

Response from Dr. Frascino


The first step is to learn a bit more about HPV. I'll post an item from the archives below that addresses the basic facts about HPV. It addresses most of the specific questions you raise. The next step is to find out if your boyfriend has HPV or not. His HIV specialist will screen him. If you have additional questions after that, write back and I'll try to assist.

Be well. Stay well.

Dr. Bob

Human papillomavirus (HPV) February 22, 2006

What Is HPV?

How Is HPV Detected?

Can HPV Infection Be Prevented?

How Are HPV Infections Treated?

The Bottom Line

NOTE: In the U.S., counseling and referrals are available on a national human papillomavirus (HPV) hotline. Call toll-free at 877-HPV-5868 (877-478-5868). Hours are from 2 p.m. to 7 p.m. Eastern Standard Time Monday through Friday.

What Is HPV?

There are over 100 viruses known as human papilloma virus (HPV). They are common. One study found HPV in 77% of HIV-positive women. HPV is transmitted easily during sexual activity. In fact, it is estimated that 75% of all sexually active people between ages 15 and 49 get at least one type of HPV infection.

Some types of HPV cause common warts of the hands or feet. Infections of the hands and feet are usually not transmitted through sexual activity. Several types of HPV cause genital warts on the penis, vagina, and rectum. Those with HIV can get worse sores in the rectum and cervical area. HPV can also cause problems in the mouth or on the tongue or lips. Other types of HPV can cause abnormal cell growth known as dysplasia. Dysplasia can develop into cancers of the penis and anus, and cervical cancer in women.

Dysplasia around the anus is called anal intraepithelial neoplasia (AIN). The epithelium is the layer of cells that cover organs or openings in the body. Neoplasia means the new development of abnormal cells. Anal intraepithelial neoplasia is the new development of abnormal cells in the lining of the anus.

Dysplasia in the cervical region is called cervical intraepithelial neoplasia (CIN). One study found AIN or CIN in over 10% of HIV-positive men and women. Another study showed that women with HIV infection have a much higher rate of CIN than HIV-negative women.

How Is HPV Detected?

To detect HPV, health care providers look first for dysplasia or genital warts. Dysplasia can be detected by Pap smears. They are usually used to check a woman's cervix. They can also be used to check the anus in men and women. A swab is rubbed on the area being checked to pick up some cells. They are smeared on a glass slide and examined under a microscope.

A new HPV test called a reflex test is being used to follow up on Pap smear results that are not clear. It can indicate who needs more careful examination or treatment. The reflex test identifies which types of HPV are present and can indicate if aggressive treatment is needed.

Some researchers believe that anal and cervical smears should be checked each year for people with elevated risk:

People who have had receptive anal intercourse.

Women who have had cervical intraepithelial neoplasia (CIN).

Anyone with under 500 CD4 cells.

However, other researchers think that careful physical examination can detect as many cases of anal cancer as anal Pap testing.

Genital warts can appear anywhere from a few weeks to a few months after you are exposed to HPV. The warts might look like small bumps. Sometimes they are fleshy and look like small cauliflowers. They can get bigger over time. Your health care provider can usually tell if you have genital warts by looking at them. Sometimes a tool called an anoscope is used to look at the anal area. If necessary, a sample of the suspected wart will be cut off and examined under a microscope. This is called a biopsy.

Genital warts are not caused by the same HPV that causes cancer. However, if you have warts, you may have also been exposed to other types of HPV that could cause cancer. Can HPV Infection Be Prevented?

There is no easy way to tell if someone is infected with an HPV. People who don't have any signs or symptoms of HPV infection can transmit the infection.

Condoms do not totally prevent transmission of HPV. HPV can be transmitted from person to person by direct contact with infected areas that aren't covered by a condom. To get the best protection from condoms, use them every time. Put them on before any contact with a possibly infected area.

Men and women with HIV who are sexually active may want to have a regular Pap smear, anal and/or vaginal, to check for abnormal cells or early signs of warts. A positive result can be followed up to see if treatment is needed. Promising preventive vaccines against some HPV types are being developed.

How Are HPV Infections Treated?

There is no direct treatment for HPV infection. Some people "clear" an HPV infection (are "cured"). They can later be infected with HPV again. Dysplasias and warts can be removed. There are several ways to do this:

Burning them with an electric needle (electrocautery) or a laser.

Freezing them with liquid nitrogen.

Cutting them out.

Treating them with chemicals like Trichloroacetic Acid (TCA), Podophyllin or Podofilox. NOTE: Podophyllin and Podofilox should not be used by pregnant women.

Other, less common treatments for warts include the drugs 5-FU (5-fluorouracil) and Interferon-alpha. 5-FU is a cream. Interferon must be injected into the warts. A new drug, imiquimod (Aldara®), has been approved for treatment of genital warts. Cidofovir (Vistide®), originally developed to fight cytomegalovirus (CMV), might also help fight HPV. A new drug called HspE7 has shown benefits in early research.

HPV infection can last for a long time, especially in people who are HIV-positive. Dysplasia and warts can return. They should be treated as soon as they are found to reduce the chances of the problem spreading or returning.

The Bottom Line

Human papilloma viruses (HPV) are fairly common. Different types of HPV cause warts or abnormal cell growth (dysplasia) in or near the anus or cervix. This abnormal cell growth can result in cervical or anal cancer. Genital HPV infections are transmitted through sexual activity.

HPV infection can last a long time, especially in people with HIV.

A Pap smear can detect abnormal cell growth in the cervix. It can also be used to check the anus of men and women. Although Pap smears may be the best way to detect early cervical cancer, careful physical examination may be the best way to detect anal cancers.

The signs of HPV infection -- warts or dysplasia -- should be treated as soon as they show up. Otherwise, the problem could spread and be more likely to return after treatment.