Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, and most people appear to be exposed to the virus shortly after their first sexual experience. Similar to other gynecological conditions, HPV infection is detected more frequently, is more persistent and is more difficult to treat in women living with HIV compared to HIV-negative women. Regular monitoring is the best way to ensure that any problems are detected and treated as soon as possible. This article will highlight some of what is known about HPV and HIV.
HPV is very easily transmitted from person to person, and condoms cannot prevent HPV transmissions as warts around the genital area may shed virus to skin that is not protected by a condom. In most cases, HPV-related disease (genital warts or a pre-cancerous condition called dysplasia) may not develop at all or take years or decades to develop. In addition, the risk of recurrence after treatment is low, suggesting in general that HPV treatment is effective. As with most viruses, however, even when an HPV-related condition isn't present (like when warts respond to treatment and go away), a person still has HPV infection. It's possible that warts or other HPV-related conditions can come back and/or it's possible to transmit HPV to others.
People living with HIV and others with compromised immunity are more at risk for HPV-related complications. Women living with HIV tend to have multiple types of HPV (which is associated with a greater risk of HPV-related disease), are less likely to clear HPV-related conditions (like when warts are more difficult to treat and less likely to go away) and are more likely to progress to HPV-related disease (such as warts progressing to dysplasia).
One study looking at HPV infection in both HIV-positive and -negative women suggests that HIV may be activating dormant HPV and thus increase the risk of HPV-related disease. Immune suppression decreases the body's ability to keep HPV in check. This link was recognized well before the HIV epidemic. In the case of HIV, as HIV progresses, the ability of the immune system to control HPV infection is reduced. This can result in higher levels of HPV and the development of HPV-related disease.
CD4 cell count is a marker of immune health, and HIV viral load is an indicator of how active HIV is in the body. Both of these lab tests provide information for people living with HIV to monitor their health. Studies have found links between HPV-related disease, CD4 cell counts and HIV viral load in women living with HIV. As the CD4 cell count declines and/or HIV viral load rises above 10,000 copies, women are at higher risk for having abnormal Pap smear results and developing HPV-related disease.
Having high levels of HIV (greater than 10,000 copies) has also been linked with abnormal Pap smears and the development of HPV-related disease. More specifically, high levels of HIV have been linked to high-grade dysplasia and cervical cancer (see "Human Papillomavirus: The Basics" in this issue for a description of grades of HPV-related disease). Taken together, what this information tells us is that keeping the immune system healthy and HIV under control may be useful in preventing the development of HPV-related disease.
The goal of anti-HIV therapy is to keep the level of HIV as low as possible and increase the CD4 cell count to at least above 200 and preferably much higher. The data on the impact of anti-HIV therapy on the development and persistence of HPV related disease is conflicting. Some studies have found a regression in HPV related disease, while others have found limited or no regression. The limitation of many of these studies is the time frame of the study and the length of time the participants have been on anti-HIV therapy. One study, called the Women's Interagency HIV Study (WIHS), is looking more carefully at the impact of anti-HIV therapy on HPV-related disease and more information is expected in the future.
What we do know is that HIV-positive women may face challenges when they are treated for HPV-related disease. HIV-positive women may respond poorly to the standard treatment for HPV-related disease and as a result may need multiple treatments using different methods.
The Bottom Line
Work with your doctor in developing a strategy to monitor and manage both your HIV and HPV infection. Optimally this will include regular visits -- including laboratory monitoring of your CD4 cell count and HIV levels -- with your doctor to monitor and track your immune health as well as routine GYN screening and care from a gynecologist who knows about HIV. Working with your doctor to develop an individualized strategy that suits your life-style and needs is the key to living longer and healthier with both HPV and HIV.
For more information about HPV and medical screenings, read Project Inform's publication, "Gynecological Conditions in Women With HIV."
Back to the Project Inform WISE Words March 2003 contents page.