Panic in the sheets

I first discovered HPV about a year ago -- not from politicians but through personal experience, when my ex-girlfriend told me she had contracted the virus. She had no idea whether I was the source, or whether it was the boyfriend she dated between our first and second attempts to stay together. But regardless, she told me that I'd better make sure that my new girlfriend had a pap smear. "If you were infected, you may not have known it," she said. "But you can pass it on even if you don't have symptoms." (In fact, according to most studies, 80 to 95 percent of HPV cases disappear without symptoms.)

I immediately panicked. HPV -- What the hell is that? I asked. What are the effects and how scared should I be?

My questions were hardly unique. There are more than a hundred strains of the virus, and an estimated 75 percent of sexually active people contract one of them at some point; about 20 million people in the United States have genital HPV infections at any given moment; and every year, about 5.5 million people become infected, according a 2000 Centers for Disease Control report. And yet, few of those who have to deal with HPV understand its significance. The CDC has found that healthcare providers rarely know how it relates to cervical cancer, and one national survey even found that more than 7 out of 10 American women had never heard of HPV.

How could we all be so ignorant?

Much of the problem stems from HPV's understudied status. The virus isn't new; doctors have known for decades that HPV exists. But until recently, researchers couldn't scrutinize the virus closely because they couldn't find a way to grow it outside the body. "The explosion of knowledge occurred after the mid-'80s, when technology let us simply clone the virus instead of growing it," said Dr. Keerti Shah, professor of public health at Johns Hopkins University.

The most important findings related to cancer. Several studies done in the mid-'90s showed that HPV was frequently present in patients with precancerous and cancerous cells in the cervix. In 1996, a 13-member panel of scientists at the National Institutes of Health reviewed the studies and officially confirmed that "carcinoma of the cervix is causally related to infection with the human papillomavirus (HPV)." The report also questioned the utility of condoms, noting that "the data on the use of barrier methods of contraception to prevent the spread of HPV are controversial but do not support this as an effective method of intervention."

The combination -- cancer plus suspected condom failure -- changed HPV forever. Suddenly, HPV was medically and politically significant. Politicians began to notice its existence, college students feared its spread, and sex educators rushed to include it in their curriculums.

Abstinence advocates -- funded for the first time to the tune of $50 million in the 1996 welfare reform bill -- led the way. "We've been talking about it for four or five years," says Unruh, whose organization is affiliated with several hundred abstinence-education programs throughout the country. "Most every abstinence-education provider is going to talk about STDs, and they will always talk about HPV."

Comprehensive sex educators -- those who speak about abstinence and birth control -- also began including HPV in their curriculums about five years ago. But the virus has never become a dominant part of the programs. Most of the organizations in charge of comprehensive sex ed have rejected the way that abstinence educators use HPV "as a wedge to try and discourage condom use -- to say having sex is deadly," says Elizabeth Cavendish, legal director at NARAL, the National Abortion and Reproductive Rights Action League. Instead, they focus on other clear and more immediate dangers. "The big-ticket item is AIDS, and there is no question that condoms protect against HIV," Cavendish says. "The other big-ticket item is pregnancy, and there's no question that condoms prevent against pregnancy."

Doctors and public health advocates say that HPV is also too complex and unknown to justify the kind of attention given to it by most abstinence educators. It's true, as studies have shown, that HPV is related to cancer and genital warts, that it can be passed through skin-to-skin contact, and that it's common. But these facts tend to raise more questions than they answer. When does a positive HPV test lead to cancer or genital warts? What are the risk factors for HPV infections that persist? Do condoms offer any protection against the spread of the virus, and if so, how much? Is there an effective form of therapy?

Those are the unanswered questions cited by the CDC as key challenges to understanding and eradicating the virus. There are no clear answers to any of them, despite the increased interest in HPV from medical researchers. Nor are they the only queries that doctors want to figure out.

Jim Rothenberger, the Morse alumni distinguished teaching instructor of public health at the University of Minnesota, says that at least three more questions need to be answered before HPV can be taught within a nonpolitical framework. "What percentage of infections actually do go on from basic infection to a disease stage where you can see something? Does it really leave the body, or does it simply hide somewhere like chicken pox? And can we get a vaccine out there?"

Liberal sex educators tend to admit that the uncertainty exists. "The hard thing for us and a lot of people is that it's still being studied," says Tamara Kreinin, president of the Sexuality Information and Education Council, a sex-education nonprofit. "Speaking clearly about it is a hard thing." But the abstinence-only crowd, with its focus on absolutes and its disdain for relativism, continues to emphasize only the facts that line up with its mantra of abstinence.

Next Page: A distinct, incorrect impression that sex is as dangerous with condoms as without

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