I think the most consistent topic I rant on and on about on my Instagram page has to be about HPV (a.k.a. the human papillomavirus). I know you may be sick of this, but let me explain why I go on about it below whilst also presenting you with a summarised fact sheet about HPV for easy access.

First things first….

The facts

• Cervical Cancer is the 3rd most common cancer amongst women worldwide and 4th in Sri Lanka for women between the age of 15 and 44 years (check out this link!).
• Every year in Sri Lanka, more than 1000 new cases of cervical cancer are diagnosed and more than 600 deaths occur due to cervical cancer – clearly, we should be concerned!
• HPV has been found to cause almost every case of cervical cancer (more than 96% of cases).
• Additionally, some forms of anal, vulval, vaginal, penile and oropharyngeal cancer are also caused by HPV.

Gardasil – one of the HPV vaccine brands available

The vaccine

Logically – if you have a vaccine targetting the HPV virus, you can then essentially prevent women from acquiring cervical cancer (reducing deaths!). So this is what the scientists tried to do, but they faced a major challenge.

• There are over 100 strains of HPV present – how can you target them all?

With further analysis, it was found that of these strains, type 16 & 18 are the most prevalent accounting for more than 80% of cervical cancers.

• So the first vaccines (Gardasil & Cervarix) targetted these two strains.
• Additionally, the Gardasil vaccine also protects against strains 6 & 11, which have been found to cause more than 90% of genital wart cases.
• Gardasil now has developed the Gardasil-9 vaccine which covers 9 strains of the virus (6, 11, 16, 18, 31, 33, 45, 52, and 58). This is NOT yet available in Sri Lanka.

Now keep that in mind whilst we digress a little bit onto more about the mode of transmission of HPV and its’ actions.

The life of a virus

HPV is spread not just via any type of sexual intercourse, but also via skin-to-skin genital contact. It is so easily transmittable that it is presumed that almost every woman will have had an HPV infection at least once in their lifetime. The tricky part is that you will experience absolutely no symptoms when you are acutely infected with the virus so you won’t have a clue. Most of the time your body can fight off the infection, but not always and these are the times when the infection can cause changes in the cervical cells (dysplasia and then metaplasia). These cell changes are pre-malignant and have the potential to become cancerous.

A metal speculum

How can these changes be detected?

The time duration between cell changes and cancer forming does NOT happen overnight. It takes a number of years for cancer to develop. As no symptoms are present until it might be too late, it is important that women (especially over the age of 25 years – if sexually active) do regular Pap smears (every 3-5 years).

During a pap smear examination, a small instrument known as a speculum is gently inserted into the vagina. It is not painful, but maybe a little uncomfortable. A quick inspection occurs and a brush tool is used to take a brush sample of cervical cells. The cells are then analysed under a microscope to check for any abnormality.

Recommendations for cervical screening around the world

Different countries have different recommendations on cervical screening. Slowly but surely, testing for the human papilloma virus (HPV testing) itself instead of looking at the cervical cells is being used more frequently. The sample for HPV testing is obtained the same way as a cervical cell smear is.

Current UK guidelines state that between the age of 25 and 49 years, a pap smear should be done every 3 years. Thereafter the time interval increases to every 5 years till the age of 64 years. If abnormal cells are found on the smear, then HPV testing is indicated. (HPV testing alone is not recommended in the UK, but this again might change in the future. A urinary test for HPV is also in the works and this will be awesome!)

The current ACOG (american guidelines) recommends pap smear testing alone every 3 years between the age of 21-30 years. Thereafter women are asked to do pap smears every 5 years together with HPV testing till the age of 65 years (a pap smear alone every 3 years is also acceptable).

In Australia, a pap smear every 2 years was recommended but not that has changed to HPV testing alone every 5 years IF the initial Pap smear test has been done 2 years prior AND was negative.

So I recently found in Sri Lanka that after the age of 35 years, women are required to get pap smears (the HPV testing is not commonly done here) every 5 years after registering with their public health midwife. However, this has poor (and laughable) coverage which is why I believe it is so important for us Sri Lankan women to take matters into our own hands and go for testing. You can get it done in the private sector or by inquiring at your local MOH clinic/hospital.

Who gets the vaccine?

Ideally, the vaccine must be given before exposure to the virus – so before sexual activity can take place. As there is no way to predict when someone will become sexually active, the vaccine is currently given to 11 to 12-year-olds (sixth graders). In Sri Lanka, it is only given to girls, but in the UK it is given to both girls and boys as it will prevent boys from not only transmitting HPV but also reduce the risk of acquiring certain cancers (penile, anal, e.t.c.).

Let’s talk a bit more about the vaccines

There are two types of HPV vaccines available – Cervarix  & Gardasil. Both vaccines are highly effective.

Cervarix covers 2 strains (16 & 18) whilst Gardasil covers 4 strains of HPV (6, 11, 16 & 18).

If given before their 15th birthday, it is a 2 dose course. If after their 15th birthday, then its a 3 dose course. So the 2 dose course is you get the first dose and then get the 2nd dose 5-6 months later. In the 3 dose course, you get the 1st dose, then the 2nd dose is 1-2 months after the 1st dose and the final dose is 5-6 months after the 1st dose.

Some important points to remember

• The vaccines only cover the most prevalent HPV strains. As there are many other strains of HPV, it is important that women who are vaccinated still get regular pap smears.
• Condoms do not eliminate transmission of the virus.
• The risk of acquiring HPV increases with the number of sexual partners.
• All persons who have a cervix (including transmen, women who identify as lesbian/queer) should get regular cervical screening after the age of 25 years.
• Pap smears are usually avoided if pregnant.
• Women who have undergone hysterectomies (removal of the uterus/womb), may still need to have pap smears done if they have had subtotal hysterectomies (the cervix is not removed).