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What’s the best approach to HPV prevention?
Lawmakers and health advocates clash
A U.S. congressman caused a stir in public health and sexually transmitted disease (STD) prevention circles in December by accusing federal health officials of failing to comply with federal law and asking them to testify at a special hearing.
In a Dec. 22, 2003, press release titled "CDC Violates HPV Report Law," U.S. Rep. Mark Souder (R-IN), chair of the House Subcommittee on Criminal Justice, Drug Policy, and Human Resources, accused the U.S. Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) of failing to comply with requirements in a 2000 federal law aimed at improving treatments for and public education about breast and cervical cancer.
Public Law 106-554, also known as the Breast and Cervical Cancer Treatment Act, was signed into law by President Clinton in 2000. Among the law’s provisions was a requirement that the CDC prepare and release a report by Dec. 21, 2003, detailing the best strategies for prevention of the spread of human papilloma virus (HPV), the most common sexually transmitted disease in the United States. Certain strains of HPV are strongly linked to the development of cervical cancer.
The law also required the FDA to re-examine condom labels to determine whether they are "medically accurate."
Both agencies failed to comply with these mandates, Souder alleged. "The CDC and FDA are today in violation of federal law, and the health of thousands of women is at risk as a result," he stated in the press release. "We are deeply concerned whenever a federal agency fails to abide by the law, but especially so when the public’s health is threatened."
To address the issue, Souder asked leaders in both agencies to testify before the subcommittee at a Jan. 28 hearing.
The hearing was later postponed after CDC officials announced they intended to release a report in January, noted Martin Green, a spokesman for the congressman.
The called hearing is an attempt by Souder to ensure that cervical cancer prevention and treatment continues to get the attention it deserves and will be rescheduled once the report is reviewed and the different witnesses can be available to give testimony, he said.
"At this point, the representative is pleased with what he has seen in the [CDC] report and the issues addressed," Green added.
However, some public health advocates feel the congressman may be pushing the hearings in order to forward a political — not health — agenda.
"We were concerned by the title of the press release for the hearing, CDC Violates HPV Report Law,’" says Deborah Arrindell, senior director of health policy at the American Social Health Association (ASHA). "It makes it difficult to feel confident that the hearing will focus on positive prevention efforts. The real focus should be on preventing cervical cancer."
Instead, health officials say, the true focus of the hearings and the requirements in the law is to garner support for funding of abstinence-only STD prevention and education programs by attacking public health messages advocating condom use.
In 1999, then-Rep. Tom Coburn (R-OK), a physician and proponent of federal funding for abstinence-only family planning and sex education programs, successfully attached an amendment to the House version of the Breast and Cervical Cancer Treatment Act requiring condom packages to carry a warning label indicating they offered "little or no protection" against HPV.
The final version of the bill altered this directive to require only that the FDA study the labeling issue and that the CDC issue a report.
In fact, Souder cites a 2001 report from the National Institute of Allergy and Infectious Diseases concluding that condom use could not be shown to reduce the risk of HPV infection.
While it’s true that the full effectiveness of condoms in preventing HPV still is unknown, there is evidence that condoms may reduce the risk of developing cervical cancer in people exposed to HPV, Arindell says. And condoms have been shown to significantly reduce the risk of contracting other sexually transmitted diseases, particularly HIV and hepatitis B and C.
"We know, if only anecdotally, that people get confused by [use of the terms] HPV, HIV, and HSV — all sexually transmitted," she continues. "Simple messages work the bet. Any label on condoms should encourage people to use them. It’s the FDA’s job to determine the most appropriate labeling on condoms and other medical devices — not the members of Congress."
The report published by the CDC advocates several strategies to prevent HPV transmission and cervical cancer, Arindell says.
It mentions abstinence from sexual intercourse, monogamy, and the use of condoms as preventive measures. In addition, it recommends more research into current provider knowledge and practices, and the concerns of women diagnosed with HPV in order to develop new prevention messages and strategies.
Studies indicate that HPV can be spread through intimate skin-to-skin contact, not just in bodily fluids, so abstinence may be the best way to avoid contacting the infection, she notes. But, most people will not remain abstinent and they will be at risk of contracting other STDs if they do not use condoms.
"Seventy-five to 80% of sexually active Americans will be infected with HPV at some point in their lives," she says. "Pretty much anyone who has ever had sexual relations has a high chance of being exposed. Abstinence is a public health message that ASHA supports, but we don’t think it can be the only message."
Surveys indicate that more than 90% of Americans have sex before marriage, and public health messages must reflect the real world, not a particular ideology, she says.
"Decreasing condom use among sexually active individuals will not reduce the prevalence of HPV," she adds. "However, it will put sexually active individuals at risk of life-threatening STDs such as HIV. For people who are sexually active, the regular and correct use of condoms remains the best protection against the transmission of STDs."