Love, sex and HPV

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Last week Sunday a member of the community in which I work succumbed to advanced cervical cancer. She was 34 years old,  and had a teenage daughter. Another of my patients, one of the upstanding elders in the same community,  who had been a rock of support for the young lady who died, was the one who told me the sad news. She then said to me “Doc, I hear that the doctor at the hospital seh is catch she catch the cancer from her partner. Something can go so?”

As it turned out, I had just finished preparing a short document for my daughters’ high school on HPV vaccination, which the Jamaican government has started providing through the high schools for seventh grade girls. So I was well prepared to answer her question, and proceeded to explain how HPV (human papilloma virus) infection can lead to cervical cancer,  how Pap smears can detect the precancerous changes in the cervix, and allow us to treat and cure when the condition is detected early. I also brought up the vaccination program that is now coming on stream, and how it can help to prevent the infection in the first place.

In this day and age with information so easily available, it blows my mind that a woman, younger than I am, can die such a horribly painful death from something that is not only treatable, but these days also preventable. I realised as I did my own research, that it is not the lack of information per se but the lack of information in context. We cannot talk about vaccinating for a sexually transmitted infection, without talking about human sexuality. Yet many of guidelines I found, from reputable sources like the Centre for Disease Control,  advised physicians to recommend the vaccine to parents of 9-11 year olds, as simply one of a bunch of recommended immunizations, and leave it up to the parents to choose when to discuss “sex” with their children. How many of us feel fully comfortable and competent as parents to have such a discussion with our kids? How many of us actively work to acknowledge, and overcome the discomfort, and find a way to talk to our children about human sexuality and all it entails?

So, although I originally prepared the article for use by my daughters high school, in light of the happenings of the past week, I am sharing it here, in the hopes that needless suffering  in the future can be avoided. It is not my usual type of post, but I hope it will at least get us talking in our own communities and families about what we can do to keep each other safe.

Part 1: The Facts

The womb or uterus is part of the female reproductive system. It can be thought of as the cradle in which a fertilised egg grows into a fully formed baby. The lower part of the uterus is called the cervix uteri, or more commonly just the cervix. This small part of the female body acts as a gateway into and out of the uterus, and cannot be seen from the outside without special medical instruments. Even though it is tucked safely away from sight, the cervix is vulnerable to attack by germs that enter the vagina during sexual activity. Some of these infections can lead to life threatening illnesses like cancer of the cervix, which is both preventable and potentially curable. In Jamaica, cervical cancer is the second most common cause of cancer death. Worldwide it is the fifth most common cancer overall, and the second commonest cancer in women.

Human papilloma virus (HPV) causes warts and cancers in humans. More than 100 different strains (serotypes) of HPV exist, of which about 15-20 are known to cause cancers (cervical, penile, vulval, anal, oral). More than 70% of cervical cancers are caused by with infection HPV type 16 and 18. More than 90% of non-cancerous warts are caused by HPV types 6 and 11. One effective way of preventing HPV infection is by vaccination.

Currently available vaccines contain viral parts capable of triggering an immune response without causing an infection. Both vaccines are given as injections, usually in the upper arm. The vaccination schedule for girls under 15 years is 2 doses at least 6 months apart. For girls over 15 years, 3 doses are required. According to the Center for Disease Control (CDC) guidelines, the series can be completed using any combination of the HPV vaccine brands provided the intervals between injections are adhered to. The types of available vaccines and what they cover are summarised in the table below.

Vaccine type

Year of approval

Who is it for ?

What strains does it protect against?

What diseases does it protect against?

Gardasil

2006

Girls and boys

16, 18, 6 and 11

Cervical cancer and genital warts

Cervarix

2009

girls

16 and 18

Cervical cancer

Gardasil 9

2014

Girls and boys

6, 11, 16, 18, 31, 33, 45, 52, 55

Genital warts, and cervical ,vulval, anal cancers

The side effects are minimal, the commonest being pain at the injection site. Fainting, which can happen after any medical procedure has been reported in some cases. To prevent injury from this, the injection is given with the patient sitting or lying down, and the patient kept seated for 15 minutes after vaccination.

These vaccines have been part of regular vaccination schedules in the USA ( 2006), in France and Canada (2007), the UK, Bermuda and Panama (2008), St Maarten, Trinidad and Tobago (2013), Barbados (2015),. In Jamaica, Cervarix is the vaccine that is currently being offered to seventh grade girls as part of the national HPV vaccination campaign, but all three vaccines are available through the private sector. They prevent infection only if given before exposure to and infection with the types of HPV that the vaccines are active against. So vaccination needs to occur before sexual activity begins, hence the age recommendations. The most powerful protection is provided when given before age 15. The bottom line is that properly administered vaccination against HPV will prevent the infections that cause more than 70% of cervical cancer.

Part 2 : The Big Picture

Although HPV infection is needed to cause cervical cancer, the presence of HPV alone is not sufficient to cause cancer. Early initiation of sexual activity, multiple partners, co-existing HIV and tobacco smoking are all well established factors that help an HPV infection to progress to cancer. So, any discussion of HPV and cervical cancer which does not look at how we can mitigate these other factors is woefully inadequate. Yet most sources of information about HPV vaccination do not address these other factors. In fact some physician guidelines go so far as suggest not bringing up the role that sexual activity plays in acquiring HPV infection, in discussions with parents about this vaccine. Perhaps one reason for this avoidance is that the vaccine is recommended to prevent what is essentially a sexually transmitted disease, but to be effective it has to be given to children who presumably would not be engaging in sexual activity.

Yet sexuality is an essential part of the human condition and is present from birth if not before. Sexuality encompasses much more than just the physical aspects of sexual activity, Many adults responsible for the care and nurture of children are uncomfortable discussing even the basic biological facts of sexual intercourse much less the wider topic of sexuality. So it is very unlikely, if left entirely up to parents and guardians, that children will receive the kind of guidance that can completely prevent infection with all types of HPV, as well as all the other maladies that result from inappropriate and maladaptive expressions of the gift of sexuality. Failure to provide children with ongoing, relevant, age appropriate guidance on human sexuality is, in my opinion, unforgivable, and avoidable. We cannot all be good at everything in life, but we all should be able to ask for, provide and accept help in areas of weakness, especially when it comes to the raising of children. If we cannot bring ourselves to personally do this type of education, then it is imperative that we find people who can deliver all the information in a sensible and sensitive way.

Human sexuality is a gift that provides us with drive and energy to pursue deep, meaningful connections with ourselves as well as others. To derive everything possible from this gift, it has to be experienced in mind body and spirit. Human sexuality is not an evil curse to be suppressed, denied or enjoyed only in guilt. Neither is it simply the superficial entertainment of mere physical acts and pleasures. Our children are bombarded with imagery and messages on both these extremes of human sexuality. As parents, teachers and caregivers of children we need to advocate for thoughtful, holistic, meaningful education on human sexuality that not only covers practical physical aspects, but also its physiological, emotional, spiritual and ethical aspects. Those of us who feel able and comfortable to discuss these things with our children should step forward. Those of us who are uncomfortable should not stand in the way of those who can provide the guidance. All of us can advocate for change in how we approach this important yet sorely neglected aspect of educating children. HPV vaccination is a good start in preventing cervical cancer, but it is only one piece of a much bigger picture.

 

One thought on “Love, sex and HPV

  1. Janett Farr

    Excellent article Kanchie. This needs to be discussed so persons can understand that young people can be subjected to Cancer of the Cervix and why. We live in a society where sex and sexual its is not openly discussed as it is taboo. Thank you for this.

    Like

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