By Alan Nyitray, PhD, and Joseph Hicks, DVM
It’s possible that you’ve been seeing more news items about HPV recently. That’s because doctors and scientists are learning more about how HPV affects men. Hopefully you’ve read about the new HPV vaccines and how they could be really important for the prevention of HPV.
But many gay men don’t know much about HPV or its role in causing anal cancer, and that may complicate efforts to prevent HPV disease in our communities.
The good news is that every day we are discovering more about HPV, cancer, and gay men. And you can be a part of these discoveries! The University of Texas School of Public Health at Houston, with the help of the medical practice of Dr. Gordon Crofoot, is currently conducting a study to teach gay men how to take their health into their own hands (quite literally). So here’s a little background about HPV and how you can get involved in this exciting research.
HPV—a Remarkably Common Disease
HPV, or human papillomavirus, is the most common sexually transmitted disease. It’s known now that almost all people—both gay and heterosexual—will get HPV at some point in their lives. It’s just part of being a sexually active human. But most of us will never know we had HPV because we won’t have any symptoms, and our bodies usually clear the virus within a few months (or maybe as long as a year or two). In this way, it’s very different from HIV.
While most of us will never know we had HPV, a small percentage of men will get one or more warts on the genitals, in the anus, or on the surrounding skin. While some men may be embarrassed by this, the warts can be treated if they don’t go away by themselves, and there’s no long-term physical danger from them. They are infectious, however, and if another guy’s penis, scrotum, etc., touches these warts, it’s very easy for him to develop an HPV infection and possibly a wart. Unfortunately, HPV can be transmitted even when warts aren’t present—it just takes close physical contact with skin that is HPV-infected. (By the way, did you ever get a wart on your hand when you were a kid? Or did you ever get a wart on the sole of your foot after walking barefoot in a gym locker room? Those are caused by a different type of HPV.)
HPV and Cancer
HPV doesn’t just cause warts. Certain types of HPV can also cause cancer, and the best estimates indicate that about 1 in 1,000 gay men may get anal cancer this year. HPV causes cervical cancer in women, and several hundred thousand women worldwide die of cervical cancer every year. In the United States and other countries that are rich enough to have widespread screening, there are far fewer deaths from cervical cancer. But still, several thousand U.S. women die every year from the disease. Most of these women would not have died if they had had regular Pap tests that screen for cervical cancer. Lesbians and bisexual women can get cervical cancer, too, and it’s just as important for them to get regular screening as it is for other women.
Gay men are at especially high risk for cancers caused by HPV. In fact, in the United States, gay men are more likely to get HPV-caused cancer than women are to get cervical cancer. It’s stunning, but one of your gay male friends is more likely to get anal cancer than your sister or mother is to get cervical cancer.
Anal cancer usually starts with an HPV infection in the anal canal that is not cleared by our immune system. The infection may start in us after receptive anal intercourse with a guy who has HPV on his penis—although you don’t have to have receptive anal sex to get HPV in your anus. (See heterosexual men, below.) A guy once said to me, “So anal sex causes anal cancer?” The answer is that just as a penis is responsible for transmitting HPV to a woman’s cervix, it can also transmit HPV to the anal canal.
For the record, women also get anal cancer; in fact, more women in the U.S. will get anal cancer this year than will men, and you may remember that Farah Fawcett had anal cancer. But gay men are at much higher risk for anal cancer than are women. In fact, at any given point in time, maybe 50 percent or more of us have anal HPV. But remember, most of these infections will clear up on their own, so only a small percentage of gay men with anal-canal HPV infection will be at risk for cancer down the road. (Interestingly, research shows that about 10 to 15 percent of heterosexual men have HPV in their anus. How it got there is still unclear, although it’s probably not because they had receptive anal sex.)
So what can we do to avoid anal cancer? Quite a bit, in fact. HPV cannot penetrate a latex condom, so those may reduce the risk of anal-canal HPV infection (and given their ability to prevent HIV infection, they make a lot of sense). Several studies also show that men who have fewer sexual partners are less likely to have anal-canal HPV. The Gardasil HPV vaccine also effectively prevents infection with the types of HPV that are most likely to cause both warts and anal cancer. The vaccine is approved for use in men younger than 27. Older guys can probably still get the vaccine, although it may be less effective. It is expensive—several hundred dollars—and it may not be effective if you already have the type of HPV that is prevented by the vaccine. (Remember, HPV is very, very common.) If you’re lucky enough to have a healthcare provider, talk to him or her about the vaccine to see if it could help you. Also, if you have health insurance, it probably covers the vaccine’s cost if you’re younger than 27.
University of Texas School of Public Health Research
So what’s the best thing to do for those of us older than 27? First, get a regular digital anal-rectal exam (DARE) from your healthcare provider. These can find anal cancer early, when it’s easy to treat. And this is where the University of Texas comes in. Our study is looking at whether we can teach gay men to screen themselves or their partners for anal cancer and other anal diseases. Right now, we are looking for gay couples to come into our Friday clinic at Dr. Crofoot’s office. There, we teach participants how to do an anal exam, ask them to take a couple of surveys, and then see how the results of their own exams stack up against a trained professional’s. All it takes is about two hours of your time on a Friday afternoon, and in return you get a free HPV exam, a free anal Pap test, and monetary compensation.
And there’s another benefit: helping increase knowledge about gay men’s health. You see, even though anal cancer is an increasingly common disease among gay and bisexual men, there are no guidelines for anal cancer screening in the U.S. On top of that, most medical schools don’t train doctors to do anal Pap tests that can identify abnormal, possibly cancerous cells. There’s not even an FDA-approved test for anal HPV.
By participating in this study, we can begin to take the screening process into our own hands. Self and partner-assisted anal exams aren’t meant to replace doctors and nurses, but just like feeling for a lump in your testicles, the goal is to find the problem early when it can still be easily treated. As with screening for cervical cancer, screening for anal cancer can prevent most cases of the disease. In fact, some healthcare providers feel that all men who have receptive anal sex should talk to their doctor and seriously consider regular screening for anal cancer. Screening can identify changes in the tissue of the anal canal that could lead to cancer if not treated.
HPV and HIV
Gay men are much more likely to get HIV infection than we are to get anal cancer. Best estimates are that about 5 in 1,000 gay men in the U.S. will get HIV this year—and men with HIV who have a suppressed immune system are at greater risk for anal cancer. (This is also the case with people who have a suppressed immune system due to drugs given during an organ transplant.) While it’s important for all gay men to get regular HPV screenings, it is especially crucial for men with HIV, so that changes in their anal canal can be caught before they proceed to anal cancer.
HPV causes other cancers, too, including cancer of the penis and of the throat. But there is even less known about these conditions than there is about anal cancer.
For more than 25 years, gay and bisexual men have been dealing with the threat of HIV. But we also know that HIV isn’t the only threat to our health. Other issues (like the threats of violence, discrimination in the workplace, and drug and alcohol dependence) are just part of the reality of being a gay man in the United States. And for the most part, we’ve been successful in navigating our way through this minefield. We get through it by learning how to take active steps to avoid things, or relying on one of our brothers to help us navigate the system. And sometimes, we’ve just been lucky.
It’s no different with the cancers caused by HPV.
Interested in participating in our study? Give us a call at 832.977.2350 or shoot us an email at [email protected]
Questions? Dr. Alan Nyitray can be reached at [email protected] Dr. Nyitray is an assistant professor and epidemiologist at the University of Texas School of Public Health at Houston. Dr. Joseph Hicks is a veterinarian (it’s a long story) and the study coordinator for the Self and Partner-Assisted Anal Exam study at the University of Texas School of Public Health at Houston. He can be reached at [email protected]