By Rebecca Bowers

EXECUTIVE SUMMARY

New research indicates that genital warts may lead to a higher risk of acquiring HIV from a partner who is infected because anogenital warts may be especially susceptible to the infection.

  • Most cases of anogenital warts are caused by nononcogenic human papillomavirus (HPV) types 6 and 11. Infection is spread via skin-to-skin contact, usually during sex. Clinicians usually will see flat, papular, or pedunculated growths on the genital mucosa, generally near the vaginal introitus, underneath the foreskin of the uncircumcised penis, and on the shaft of the circumcised penis.
  • Although genital warts can be treated, no treatment can cure the HPV virus that causes the lesions. Counsel patients that genital warts can recur after treatment, especially within the first three months.

Of the 630 million new cases of human papillomavirus (HPV) that occur worldwide each year, it is estimated that 30 million develop anogenital warts.1 New research indicates that genital warts may lead to a higher risk for acquiring HIV from a partner with the infection because anogenital warts may be very susceptible to infection with HIV.2

Researchers at Boston University School of Medicine looked at biopsy samples of genital warts, comparing the number of HIV-target cells to that found in normal tissue from the same parts of the body. They also collected genital wart samples from men who were not infected with HIV. The researchers then cultured the samples with HIV to find out if the warts were at high risk for infection with HIV.

The findings suggested that there was an increased density of HIV-target cells in the anogenital warts compared to the normal tissue of the same patient. In about 50% of the anogenital wart samples, the outermost layer of skin demonstrated high concentrations of HIV-target cells. The outer skin layer is most apt to be in contact during sexual intercourse. Of the eight samples that were cultured with HIV, two demonstrated signs of infection with HIV, suggesting that some anogenital warts may be susceptible to infection with HIV.

Such findings signify that clinicians should be more aggressive in treating genital warts, affirms corresponding study author Deborah Anderson, PhD, professor of obstetrics and gynecology at Boston University School of Medicine. These findings also have potential implications worldwide, she notes.

“Large scale roll out of HPV vaccines in HIV-endemic areas, such as sub-Saharan Africa, could significantly impact the HIV epidemic in those regions,” said Anderson in a press statement.

Ninety percent of genital warts are caused by HPV types 6 and 11. The Gardasil 9 HPV vaccine now available in the United States provides protection against those HPV types.3

Understand Treatment Options

Nononcogenic HPV types 6 and 11 cause most cases of anogenital warts. Infection is spread via skin-to-skin contact, usually during sex. Depending on the wart size and location, some of them can cause pain or itching. Patients typically present with flat, papular, or pedunculated growths on the genital mucosa. In women, this generally occurs around the vaginal introitus; in men, it appears underneath the foreskin of the uncircumcised penis, and on the shaft of the circumcised penis. Appearance of warts also can occur in the anogenital epithelium as well as in the cervix, vagina, urethra, perineum, perianal skin, anus, and scrotum. Although intra-anal warts usually occur in people who have had receptive anal intercourse, they also can occur in people who do not have that history.4

The Centers for Disease Control and Prevention 2015 STD Treatment Guidelines recommend using the following factors to guide treatment of anogenital warts: the size, number, and site of the warts; the patient’s preference; cost of treatment; convenience; adverse effects; and experience of the provider. There is no definitive evidence indicating the superiority of one treatment to another, and no individual treatment is best for all patients or in all cases, the guidance states.4

Recommended patient-applied treatments for external anogenital warts include 3.75% or 5% imiquimod cream; 0.5% podofilox solution or gel; or 15% sinecatechins ointment.3

If imiquimod or sinecatchins is prescribed, remind patients that either treatment may weaken condoms or diaphragms.

Clinicians also may use one of the following provider-applied approaches for treatment:

  • Cryotherapy using liquid nitrogen or cryoprobe; OR
  • Surgical wart removal via tangential scissor excision, tangential shave excision, curettage, laser, or electrosurgery; OR
  • Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) 80-90% solution.4

Remind patients that although there is treatment for genital warts, there is not a cure for the HPV virus that causes the lesions. Counsel patients that warts can recur after treatment, particularly in the first three months. With correct and consistent use, condoms may reduce the chances that genital warts will be transmitted to a partner. However, HPV can occur in areas that the condom does not cover, so they may not provide full protection against the virus. Although the HPV vaccine can help protect against the virus types that cause anogenital warts, it will not treat HPV infection or genital warts that already exist.4

Scientists have been exploring the safety and efficacy of a topical antiviral gel called Teslexivir to treat anogenital warts. In a Phase II, double-blind, randomized, placebo-controlled trial, researchers found complete clearance of warts by week 16 in 30.6% of patients treated with Teslexivir compared to 23.3% of those in the placebo group. However, the researchers noted that the difference was not statistically significant. The company developing the potential drug is analyzing the results further.5

REFERENCES

  1. de Camargo CC, Tasca KI, Mendes MB, et al. Prevalence of anogenital warts in men with HIV/AIDS and associated factors. Open AIDS J 2014;8:25-30.
  2. Pudney J, Wangu Z, Panther L, et al. Condylomata acuminata (anogenital warts) contain accumulations of HIV-1 target cells that may provide portals for HIV transmission. J Infect Dis 2018; doi: 10.1093/infdis/jiy505. [Epub ahead of print].
  3. Joura EA, Pils S. Vaccines against human papillomavirus infections: Protection against cancer, genital warts or both? Clin Microbiol Infect 2016;22 (Suppl 5):S125-S127.
  4. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64:1-137.
  5. Vaxart Inc. Vaxart reports topline results from phase 2 trial of Teslexivirtm for the treatment of condyloma. June 4, 2018. Available at: https://bit.ly/2oHyIRO. Accessed Sept. 20, 2018.