For men, the potential consequences of infection by the human papillomavirus are nasty, like genital warts, and even life-threatening, such as penile and anal cancers. But these complications are quite rare. For the average guy, the virus lies silent, doesn't cause problems, and clears in a year or two.
Still, HPV is the most common sexually transmitted disease in the United States, and the federal Advisory Committee on Immunization Practices is deliberating whether to issue a public recommendation that boys and men be vaccinated with Gardasil, the only HPV vaccine approved for that group, just as it's recommended for women. There is no easy answer. Experts must weigh the cost of immunizing against the benefits, which could include fewer cases of HPV-related cervical cancer in female partners but most of the time is just about staving off a few relatively harmless warts. They also want to wait and see whether the U.S. Food and Drug Administration will allow Gardasil maker Merck to market the vaccine for the prevention of anal cancer; currently it is approved for preventing cervical cancer in females between the ages of 9 and 26 and genital warts in males and females in that same age group. The FDA is expected to make a decision by the end of the year. ACIP officials will consider the FDA's action in making their recommendation, which could come as soon as February, says Lauri Markowitz, leader of ACIP's HPV working group. For now, though, men and parents of boys are on their own. They can request the three-shot series, and doctors are free to provide it.
So far, however, demand has been underwhelming. "Let's just say they're not knocking down the doors asking for it," says Michael Rich, an associate professor of pediatrics at Children's Hospital Boston. And from a professional perspective, he says, "it's not a standard protocol for your average 11-year-old boy, you know, troopin' in for his physical." But it's still something some parents will ponder.
The decision may be easier for men and parents who believe that males and females have a shared responsibility in preventing STDs. Johns Hopkins Bloomberg School of Public Health professor Neal Halsey falls into that group. Widespread vaccination, he says, is the best way to control HPV and avoid its potentially serious effects—and it's also the most ethical. Men infected with one of a few strains of HPV who pass it on to female sexual partners put them at risk for cervical cancer if they haven't been vaccinated themselves, which the government advises to prevent that form of cancer. And men who have sex with men are at greater risk for HPV-related anal cancer, which affects 1,100 men a year.
Vaccinating boys when they are 11 or 12 would be the most effective timing, catching the vast majority of them before their "sexual debut," says James Turner, the American College Health Association's liaison to ACIP and director of the University of Virginia's Student Health Center.
Besides cancer, the thought of genital warts alone may convince a man to get vaccinated, says Turner. The warts, which affect about 1 percent of sexually active men at any given time, typically aren't painful, respond readily to freezing with a little liquid nitrogen at the doctor's office or even an at-home gel, and are considered a fairly "trivial medical condition," he says. But he still regards them as destructive. The warts can pop up months or years after the initial infection. In the interim, a man wouldn't know if he was infected. If he develops a close relationship, his significant other would need to take his word at the start that he was free of HPV. And if he develops genital warts later, his other half would also have to take on faith that he really did contract the virus before they got together. "Believe me, a genital wart can be a devastating occurrence in an otherwise monogamous intimate relationship," says Turner, basing his view on the college students he has worked with. At the University of Virginia, roughly 10 percent of the current male population have been vaccinated. That's pretty high, he says, most likely because of an active gay and bisexual community and a student health plan that covers the three-shot vaccine's $400 price tag.
While most experts agree Gardasil is effective for both men and women, it's not the only option. Condoms lower the chance of transferring HPV by 80 to 90 percent, says Turner, but they're not foolproof; the virus can pass through uncovered skin. And of course, limiting sexual partners can help, but one infected partner is all it takes.
Experts also generally agree that the vaccine is safe. Since Gardasil was approved for females in 2006, more than 32 million doses have been administered in the U.S. Of about 17,000 accounts of post-vaccination problems submitted to the Vaccine Adverse Event Reporting System, roughly 8 percent, or .004 percent of the total number of doses, describe issues considered serious—such as Guillain-Barré Syndrome, which causes muscle weakness, and blood clots in the heart, lungs, and legs—almost all of which have occurred in women. No hard evidence, however, ties these issues to the vaccine. Most side effects are minor, such as fainting and pain at the injection site. The cost might not be covered by all health insurers; if that could be a problem, it would be wise to check. The Vaccines for Children Program, funded by the federal government, provides the vaccine to eligible children 18 and younger for free if money is an issue.
Primary care physicians can walk a man or a boy's parents through the pros and cons of getting vaccinated, says Rodney Willoughby, a professor in the department of pediatrics at the Medical College of Wisconsin and a member of the American Academy of Pediatrics' Committee on Infectious Diseases. Don't shy away from the issue because it's controversial, he says, or because you're worried about broaching the "birds and the bees" talk; there are ways around it. Simply telling your son, "It could protect you against cancer," might be enough. Many parents and men will undoubtedly wait for word from the federal government, and that's O.K., too, Turner says. "It's certainly reasonable to wait and see if ACIP comes up with a more specific recommendation," he says. "There's no urgency."