HPV is the most common sexually transmitted infection in the United States. In the United States, an estimated 79 million persons are infected, and an estimated 14 million new HPV infections occur every year among persons age 15 through 59 years. Approximately half of new infections occur among persons age 15 through 24 years and the first HPV infection typically occurs within a few months to years of becoming sexually active.
Ask the Experts: HPV (Human Papillomavirus)
Most HPV infections are asymptomatic and go away completely on their own within 2 years (usually in the first 6 months) after infection without causing clinical disease. Some infections are persistent and can lead to precancerous lesions or cancer. HPV infections caused by certain HPV types cause almost all cases of anogenital warts in women and men and recurrent respiratory papillomatosis.
According to CDC surveillance data from 2015 to 2019, every year in the United States, about 47,199 new cases of cancer (26,177 among women and 21,022 among men) are found in parts of the body where human papillomavirus (HPV) is often found (referred to as HPV-associated cancers). About 79% of these cancers are probably caused by HPV (referred to as HPV-attributable cancers).
Each year, between 2015 and 2019, an average of 12,293 cases of cervical cancer, the most widely known HPV-associated cancer, occurred in the United States. HPV is also associated with vulvar, and vaginal cancer in females, penile cancer in males, and anal and oropharyngeal cancer in both females and males. Between 2015 and 2019, oropharyngeal cancers were the most commonly occurring HPV-associated cancers, with an average of 20,839 reported cases each year (17,238 among men and 3664 among women). See www.cdc.gov/cancer/hpv/statistics/cases.htm and www.cdc.gov/cancer/uscs/about/data-briefs/no31-hpv-assoc-cancers-UnitedStates-2015-2019.htm for more information on trends in HPV-associated cancer.
In the United States, approximately 64% of HPV-related cancers are attributable to HPV 16 or 18, two types included in all HPV vaccines. Approximately 10% are attributable to HPV types 31, 33, 45, 52, and 58, which are included in the 9-valent HPV vaccine.
HPV types 6 or 11 cause 90% of anogenital warts (condylomata) and most cases of recurrent respiratory papillomatosis.
There is no treatment for HPV infection. Only HPV-associated lesions including genital warts, recurrent respiratory papillomatosis, precancers, and cancers are treated. Recommended treatments vary depending on the diagnosis, size, and location of the lesion. Local treatment of lesions might not eradicate all HPV containing cells fully; whether available therapies for HPV-associated lesions reduce infectiousness is unclear.
Occupational infection with HPV is possible. Some HPV-associated conditions (including anogenital and oral warts, anogenital intraepithelial neoplasias, and recurrent respiratory papillomatosis) are treated with laser or electrosurgical procedures that could produce airborne particles. These procedures should be performed in an appropriately ventilated room using standard precautions and local exhaust ventilation. Workers in HPV research laboratories who handle wild-type viruses or “quasi virions” might be at risk of acquiring HPV from occupational exposures. In the laboratory setting, proper infection control should be instituted including, at minimum, biosafety level 2. Whether HPV vaccination would be of benefit in these settings is unclear because no data exist on transmission risk or vaccine efficacy in this situation.
Nonsexual HPV transmission is theoretically possible but has not been definitely demonstrated. This is mainly because HPV can’t be cultured and DNA detection from the environment is difficult and likely prone to false negative results.
- If a person is infected with an HPV strain that does not clear (that is, the person becomes persistently infected) the person cannot be reinfected because they are continuously infected.
- If a person is infected with an HPV strain that clears, some but not all people will have a lower chance of reinfection with the same strain. Data suggest that females are more likely than males to develop immunity after clearance of natural infection.
- Prior infection with an HPV strain does not lessen the chance of infection with a different HPV strain.
Gardasil 9 (9vHPV, Merck) is the only HPV vaccine being distributed in the United States. Bivalent Cervarix (2vHPV, GSK) and quadrivalent Gardasil (4vHPV, Merck) are no longer being distributed in the United States.
9vHPV is an inactivated 9-valent vaccine licensed by the Food and Drug Administration (FDA) in 2014. It contains 7 oncogenic (cancer-causing) HPV types (16, 18, 31, 33, 45, 52, and 58) and two HPV types that cause most genital warts (6 and 11). The 9vHPV vaccine is licensed for females and males age 9 through 45 years.
The ACIP recommends that routine HPV vaccination be initiated for all children at age 11 or 12 years. ACIP notes that vaccination may be started at age 9 years, if preferred. There is no down-side to beginning the series at age 9, and this option gives more time to complete the series before the 13th birthday. Vaccination is also recommended for all people age 13 through 26 years who have not been vaccinated previously or who have not completed the vaccination series.
No. In June 2019, the Advisory Committee on Immunization Practices (ACIP) voted to recommend routine catch-up HPV vaccination of all previously unvaccinated or incompletely vaccinated males age 22 through 26, the same as the recommendation for females. HPV vaccination recommendations differ by age group. There is a routine recommendation for vaccination of all people 9 through 26 years of age and a shared clinical decision-making recommendation based on risk and preference for people 27 through 45 years of age.
The most current ACIP recommendations for HPV vaccine are available at www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6832a3-H.pdf.
Catch-up HPV vaccination is not recommended for adults older than 26 years of age. Instead, shared clinical decision-making regarding HPV vaccination is recommended for some adults aged 27 through 45 years who are not adequately vaccinated and want to be protected from ongoing risk of acquiring new HPV infection.
Ideally, HPV vaccine should be administered before potential exposure to HPV through sexual contact.
Although new HPV infections are most commonly acquired in adolescence and young adulthood, at any age, having a new sex partner is a risk factor for acquiring a new HPV infection. In addition, some persons have specific behavioral or medical risk factors for HPV infection or disease, including men who have sex with men, transgender persons, and persons with immunocompromising conditions. HPV vaccine works to prevent infection among persons who have not been exposed to vaccine-type HPV before vaccination. A discussion with your patient is the best way to decide together how much the patient may benefit from HPV vaccination to prevent new HPV infections.
Because HPV acquisition generally occurs soon after first sexual activity, vaccine effectiveness will be lower in older age groups as the result of prior infections. In general, exposure to HPV also decreases among individuals in older age groups. Evidence suggests that although HPV vaccination is safe for adults 27 through 45 years, population benefit would be minimal; nevertheless, some adults who are unvaccinated or incompletely vaccinated might be at risk for new HPV infection and might benefit from vaccination in this age range.
No. No screening laboratory test can determine whether a person is already immune or still susceptible to any given HPV type. Most sexually active adults have been exposed to one or more HPV types, although not necessarily all of the HPV types targeted by vaccination. HPV vaccine works to prevent infection with vaccine types to which a person is still susceptible.
Complete the series based on shared clinical decision-making involving the patient’s risk and desire for protection.
ACIP recommends a routine 2-dose HPV vaccine schedule for adolescents who start the vaccination series before the 15th birthday. The two doses should be separated by 6 to 12 months. The minimum interval between doses is 5 calendar months.
A 3-dose schedule is recommended for all people who start the series on or after the 15th birthday and for people with certain immunocompromising conditions (such as cancer, HIV infection, or taking immunosuppressive drugs). The second dose should be given 1 to 2 months after the first dose and the third dose 6 months after the first dose. The minimum interval between the first and second doses of vaccine is 4 weeks. The minimum interval between the second and third doses of vaccine is 12 weeks. The minimum interval between the first and third dose is 5 calendar months. If the vaccination series is interrupted, the series does not need to be restarted.
Coverage levels for HPV vaccine are improving but are still inadequate. Results from the Centers for Disease Control and Prevention’s 2022 National Immunization Survey-Teen (NIS-Teen) indicate that for the first time since 2013, HPV vaccination initiation did not increase among adolescents age 13 through 17 years. HPV vaccination initiation actually fell among adolescents insured by Medicaid and remained lowest among the uninsured. The Vaccines for Children (VFC) program ensures access to HPV and other routine vaccines for adolescents who are uninsured or Medicaid-eligible at no cost. It is important that families are aware of this entitlement and the importance of HPV vaccination.
In 2022, 76% of adolescents had received at least 1 dose of HPV vaccine and 62.6% were up to date with HPV vaccination. A summary of the 2022 NIS-Teen survey and trends are available at www.cdc.gov/mmwr/volumes/72/wr/mm7234a3.htm.
Providers can improve uptake of this life-saving vaccine in two main ways. First, studies have shown that missed opportunities are occurring. Up to 90% (depending on year of birth) of girls unvaccinated for HPV had a healthcare visit where they received another vaccine such as Tdap, but not HPV. If HPV vaccine had been administered at the same visit, vaccination coverage for one or more doses could be 90% instead of 70%. Second, research has shown that not receiving a healthcare provider’s recommendation for HPV vaccine was one of the main reasons parents reported for not vaccinating their adolescent children.
CDC urges healthcare providers to increase the consistency and strength of their recommendation of HPV vaccine, especially when patients are age 11 or 12 years. CDC’s “Talking to Parents about HPV Vaccine,” available at www.cdc.gov/hpv/hcp/for-hcp-tipsheet-hpv.pdf can help providers with these conversations. In order to increase the opportunities to complete the two-dose series on time, some healthcare providers prefer initiating vaccination beginning at age 9 years. There is no down-side to initiating the series at that time.
For more detailed information about HPV vaccination strategies for providers, visit www.cdc.gov/hpv/hcp/index.html.
Explain to the parent that vaccination starting at 11 or 12 years will provide the best protection possible long before the start of any kind of sexual activity. It is standard practice to vaccinate people before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines. Similarly, we want to vaccinate children before they get exposed to HPV. Studies of HPV vaccine indicate that younger adolescents respond better to the vaccine than older adolescents and young adults. Healthy children vaccinated at this age will need only 2 doses of vaccine rather than 3 doses if vaccinated at an older age. Finally, numerous research studies have shown that getting the HPV vaccine does not make kids more likely to be sexually active or start having sex at a younger age.
No. Cervarix was not approved or recommended for use in males. Doses of Cervarix administered to males should not be counted and need to be repeated using 9vHPV.
There is no ACIP recommendation for additional doses of 9vHPV for persons who started the 3-dose series with 2vHPV or 4vHPV and completed the series with 9vHPV.