Persistent HPV

[synchronicity]

I'm female, well past the age of 26.  I take immunosuppressive drugs for a kidney transplant and had two HPV outbreaks 5 years ago, but haven't had an outbreak since then.  I'm in committed, consensually nonmonogamous relationships with Fred (4 yrs) and George (1 yr).    

When George and I met, he told me he'd had genital warts for >6 months and was about start Aldara.  After several months of no results he applied an OTC product (!) every few days for a month or two, which shrunk the warts but not completely.  He returned to his doc for freezing treatments, but after a few visits he noticed another wart... in his urethra.  As each urethral wart was removed another was revealed further down, plus a new external wart turned up; recently his doctor recommended a urologist for further treatment.

G's insurance won't pay for the urologist and he's already struggling with his co-pays.  His doc is looking for less expensive options but we're not optimistic.  We've avoided contact between his genitals and my mucous membranes, and are rigorous handwashers; we feel that protected intercourse is an acceptable risk once the warts are gone... in the meantime, aaargh.

In a monogamous relationship I'd be considering intercourse since:
- 50ish% chance I've had the same strain of HPV (possibly >1 strain)
- Aldara worked for me
- genital warts usually harmless
- relationship stable/long-term

On the other hand:
- risk to Fred (+ his other long-term girlfriend, etc.)
- my immunosuppressive therapy
- G's immune system doesn't have the virus under control yet
- Fred and George's similar concerns

Please, can you answer the following?
- is our reasoning sound? (I hope we're being overcautious)
- would Gardasil do me any good despite my age?
- should we be concerned about why this infection is so persistent?
- anything else we should be asking?

Thanks!

[Edward W Hook, MD]

I'm sorry if I am missing your point.  I there a partner has no warts and assuming this assessment is correct, there is no risk for getting them for that partner.  the only caveat here is if the partner had warts which were recently treated, they could be recurring and the recurrence could not be apparent.  For that reason we suggest clients wait at least 3 and to be completely sure, 6 months before assuming that their wart therapy has been completely successful.

The published studies of the impact of condoms on HPV risk reduction suggest that condoms reduce risk between 40 and 60%.

EWH

[Edward W Hook, MD]

Welcome to the Forum.  Your situation is a difficult one, complicated by the immunosuppressive therapy that you are receiving related to your renal transplant.  I agree with the reasoning that you have outlined above.  George needs a specialist care.  Intra-urethral warts typically require removal and/or treatment under a urologist care.  While he struggles with this, condoms and careful hygiene will go a long way towards helping.  In addition, since you had warts in the past, there is a chance that you have developed a degree of  immunity or at least resistance to infection from your prior infection, particularly if it occurred before your transplant.

The age cut off for the HPV vaccine (and you are correct to be focused on Gardasil since it is the only one which includes the wart causing HPV types) has recently been increased to 29. the prior cut off had nothing to do with the efficacy of the vaccine and more to do with the fact that younger women get most of the HPV infections.  On the other hand, your immunosuppressant therapy may reduce the efficacy of the vaccine for you.  If I were your doctor and we could get it paid for, I would recommend Gardasil for you.

Most people with persistent, difficult to treat warts are unlucky, not immunocompromised.  At the same time, it may be worthwhile for Go discuss this with his doctor and get and HIV test if he has not already.

Congratulations on the knowledge you have already gained.  I hope my comments help .  Take care. EWH

[synchronicity]

Dr. Hook,

Even if I won't be posting any more *questions*, I *would* like to thank you for your last reply; it now feels as if we have enough info to sit down and make an intelligent decision, whatever that decision might be.

[synchronicity]

Dr. Hook,

In my second post to this thread I was actually hoping to quantify the relative risks if condom use is a *given* (which it is, in this case) -- i.e. transmission risk/year with

urethral warts + condom
vs.
no warts at all + condom

I realize the best answer at the moment could be fuzzy -- "a little different," "a lot different," or even "we just know the first is higher."  

(And never fear, unless my ID doctor says anything particularly interesting, I'm done posting on this thread :) )

Thanks again,
-synchronicity

[Edward W Hook, MD]

Condoms, while not perfect, do offer substantial protection from HPV acquistion, hence my answer as to "now".

As I said, there is no age reated reason to not get the vaccine however, as your NP friend has said, you would probably have to pay for it yourself.  She is wrong about the issue of transmission risk and condoms.  Condoms have been proven to reduce HPV transmission in clinical trials.

Hope these further comments help. Tale care. EWH

[synchronicity]

Thank-you!  I'm slightly confused by your answer; are you saying that it's probably not significantly more risky to have intercourse *now* as long as we use condoms?  (vs. waiting until the warts are completely gone)  It would be wonderful if this were true as G and I are feeling worse and worse about having waited this long, but I'm not getting my hopes up.

Also, I was able to get an appt on short notice with a nurse practitioner yesterday (my gyn and most other providers who knew me well finished their residencies at the academic year).  Anyway, the NP told me that Gardasil would be impractical for a transplantee in her 40s, and it wouldn't be covered by my insurance anyway, though I do plan to explore that issue further when I've managed to get off disability.   She also feels that risk of transmission with condom + warts is roughly equivalent to condom + no warts are gone (??!!), but that I'd get a better answer from Infectious Diseases.  To be thorough I left a voicemail with my ID doc, who sees mainly transplantees; I suspect he won't tell me anything you haven't, though.

Finally, George tested HIV- in his last round of STD testing, and we know to ask for that, Western Blot, and Hep C specifically).  He hasn't chosen to seek out additional partners since we met, so fortunately we're OK there.

Of course if anything surprising happens I'll report back :)  Thanks again!