If you happen to be one of the 15 people in the world who reads the foil wrapper before ripping it open to put on a condom, the religious right wants to have words with you. The words -- right after the line that says, "If used properly, this product can help protect against HIV" -- are: "BUT NOT AGAINST HPV."
HPV is the human papilloma virus, a sexually transmitted germ that causes cervical cancer, which killed about 5,000 American women in 1999. Unlike HIV, hepatitis B, gonorrhea and other microbes, HPV spreads not only through seminal fluid or mucosal membranes during sex, but also through the rubbing together of crotch and genitals. As a result, condoms don't guarantee protection against it.
While that's unfortunate, it isn't really news. HPV has been colonizing human nether parts for centuries. Rates of cervical cancer, the major disease caused by HPV, have fallen steadily since the introduction of the Pap smear in the 1950s.
The link between HPV and cancer was identified in 1979, but has only gradually become confirmed common knowledge. Newer tests for viral DNA have enabled scientists to find the virus easily -- and they find it everywhere. That awareness has given some social conservatives an opportunity to harness science to their timeless message about the wages of sin. On the floor of the House recently, Rep. Tom Coburn, R-Okla., warned that an "epidemic of HPV infection" was sweeping the country. And a recent article for teens published by the Family Research Council, a conservative Washington group, warned darkly that HPV "shows there is no thing as safe sex. Abstaining from sex until marriage is not the only right thing to do; it's the healthy thing to do." For the religious right, it seems HPV is the new HIV.
Coburn, a family practice physician and a fierce opponent of abortion, subtly inserted the HPV message into the Breast and Cervical Cancer Treatment Act, a bill that passed by a 421-1 vote in the House of Representatives on May 9. The bill provides an estimated $250 million over the next five years to treat uninsured female cancer patients. But Coburn tacked on two controversial clauses, which went virtually unnoticed by the news media. The first orders the Food and Drug Administration to require condom labels to state that they do not protect against HPV. The second calls for the federal government to make HPV infection a reportable disease within two years.
While these don't at first glance seem like particularly insidious measures, many scientists and doctors who work on cervical cancer believe the requirements could lead to unfounded panic and loss of confidence in condoms, ultimately increasing the rate of sexually transmitted disease. The Coburn amendments, these critics say, manipulate the science to serve a poorly conceived idea.
"The subtext is that Coburn and his supporters don't want people to have sex," says a spokesman for the American College of Obstetricians and Gynecologists. "They're saying, 'Hey kids. Not only will you get AIDS. You'll get cancer, too!'"
Women's health advocates oppose the new condom warnings, and are trying to get them dropped from the final bill sent to President Clinton.
Scientists estimate that 75 percent of sexually active American women will be infected with HPV some time in their lives. But "in the vast majority of cases, the infections go away on their own" without causing any damage, says Diane Solomon, a leading NIH researcher and former president of the American Society of Cytopathologists. Some of the infections have no visible symptoms at all; others result in a treatable case of genital warts.
For those reasons, says Solomon, it doesn't make sense to test all women for HPV infection. A woman's HPV status, in and of itself, belongs in the What You Don't Know Won't Hurt You category. HPV isn't a disease -- it's a common virus, with more than 100 strains, most of which appear to be harmless.
"If we screened everyone for HPV you would be telling a lot of women, 'You have this infection that's sexually transmitted and that, on rare occasions, leads to cancer. But we don't have a treatment for it,'" she says.
"You might as well report the common cold," says Dr. Robert D. Burk of Albert Einstein College of Medicine. "Are they prepared to have CDC hire 10,000 new workers to keep track of it?"
"To tell women that HPV is like other STDs is wrong and dangerous," adds Dr. Mark Schiffman, who is in charge of cervical cancer epidemiology at the National Cancer Institute. "You have to present the whole balanced picture. Scaring people will damage public health."
Coburn's requirement for condom labeling is also misleading, critics say. Condoms protect against many germs, as well as pregnancy. There is no good data indicating how effective condoms are at stopping the spread of HPV, but many experts theorize that condoms stop the virus at least some of the time. When it comes to viruses, dose matters, as do the mechanics of the flesh. In other words, the rubbing of external parts is less effective than the vigorous intrusion of a penis in a vagina to transmit the virus.
"Condoms are effective in decreasing transmission of HPV," insists Juan Carlos Felix, a Los Angeles cytopathologist who chairs the National Cervical Cancer Coalition's medical advisory panel. "If you block most of the contact you're going to reduce infectivity tremendously. In fact, if everybody used condoms in intercourse in the U.S., the cervical cancer rate would drop to nearly zero. Not absolute zero, mind you, but close to it."
The religious right's preoccupation with HPV is an example of the ideological use of fragmentary scientific knowledge. But it casts a shadow on the positive role that doctors expect HPV testing to play in cervical cancer diagnosis and screening. Once judicious protocols for HPV tests have been established -- and the biotech company that markets them lowers its price from about $100 -- they should enable doctors to fight cervical cancer more effectively while exposing women to fewer pelvic exams.
To be sure, the Pap smear alone remains the world's most successful cancer screening method. Annual U.S. deaths from cervical cancer declined from 26,000 in 1941 to about 5,000 now as a result of the Pap smear -- and at least half those who get the cancer probably would have been spared had they gotten regular Pap smears.
Still, the procedure is by no means perfect. For one thing, it's awkward at best and frequently painful. Doctors use a cotton-tipped swab or small spatula to scrape cells from a woman's cervix and spread them on a slide; lab technicians check the slide for irregular cells. The search is not easy and technicians miss abnormal cells as much as half the time. Since it often takes 10 years for HPV infection to develop into cancer, however, a Pap exam every year will still almost always catch growths before they become life-threatening.
When growths go undetected, the results can be heartbreaking.
Vicki Little, a Coulterville, Ill., woman who had gotten a pelvic examination every year, went for her annual checkup in 1999 to discover that she had Stage 3 cervical cancer. She required a radical hysterectomy.
"I'll always wonder if the Pap I had in 1998 was read wrong," says Little, who is 27 and has two little girls. "I don't understand, and neither do any of my doctors, how it could have grown so quickly. I've thought about having my slides from '98 read again, but what good would it do? It won't change anything. I still won't be able to have any more children. I still won't have my womanhood back."
Problems like Little's led to a series of lawsuits beginning in the late 1980s. Since then dozens and perhaps hundreds of laboratories have stopped doing Pap smears, caught between the expense of liability insurance to cover misread slides and the low Pap smear reimbursements -- generally $7.15 -- for Medicare and Medicaid patients.
The problems with the Pap are partly responsible for a surge in scientific research into HPV. Studies published this year in the Journal of the American Medical Association, the Lancet and other medical journals have begun to suggest how tests for the dangerous strains of the virus might be used.
About 4 percent of all Pap smears provide an equivocal result, cellular abnormalities that may or may not be cancerous. HPV tests can be used to determine whether these borderline cases require further examination. If an HPV test shows infection by a dangerous strain of the virus, doctors proceed to take a tissue sample from the cervix to see if it is cancerous. While some doctors are already using the HPV test this way, NIH researchers want a clearer sense of the best uses for HPV before issuing standard protocols.
The U.S. system may end up something like the one in the Netherlands, where women now get a Pap smear and an HPV test simultaneously, but only once every 10 years.
"With this test," says Schiffman, "Cervical cancer should become 100 percent preventable."
In the meantime, he says, there's a lot to be learned about HPV. And when it comes to misconceptions about the virus, Coburn isn't the only one promoting them.
In fact, Schiffman fired his own wife's gynecologist after his wife was given an HPV test following a normal Pap smear. "This is a test that I helped develop, and I've dedicated my life to the intelligent use of it," he says. "But spending $100 to test a healthy American woman is not an intelligent use of it."