No-Brainer Syndrome: Using the HPV Vaccine and Male Circumcision to Fight Disease

Dr. Paul Offit, director of the Vaccine Education Center at The Children's Hospital of Philadelphia, called the new HPV vaccine, Gardasil, approved last year by the Center for Disease Control (CDC), ”a no-brainer.” Many advocates in the blogosphere use the same phrase, “no-brainer,” to describe the World Health Organization (WHO) 2006 recommendation for male circumcision as an HIV/AIDS prevention strategy, at least in sub-Saharan Africa. Most health professionals agreed, even if they didn’t use the exact phrase.

The public disagreed. A mere 10 percent of girls in the U.S. have been vaccinated so far with Gardasil and few men in Africa have had “the snip.” Within the past weeks the Virginia Legislature has taken steps to repeal its mandate for the HPV vaccine for schoolgirls, and the Health Minister of South Africa has refused to endorse male circumcision as part of its national AIDS program.

So, are these recommendations “no-brainers” or not?

They aren’t, for three reasons: 1) they might not be as effective as advertised; 2) they run the risk of diverting funds from more effective prevention strategies; and 3) there is a real risk of unintended harm to women.

Both epidemics, HPV and HIV, have certain similarities: both are viruses, both are transmitted sexually, and both flourish because of the molasses-like pace of change, or lack thereof, in the human sexual behavior needed to thwart them. The ABC (Abstinence, Be faithful, Condoms) approach has been effective in some countries in Africa and elsewhere, especially where it resulted in more condom use, but alas, condom use is not universal for many reasons -- cultural, sexual, economic and otherwise, including the prosaic fact that the worldwide condom supply is both erratic and insufficient. Alas, even when condoms are available and used, they are not universally effective against HPV/genital warts. Thus HPV and HIV march on.

In desperation the public health establishment embraced two seeming magic (and expensive) bullets in the fight against HPV and HIV: a new vaccine and a re-branding of circumcision.

The HPV Vaccine -- Gardasil

Gardasil is recommended for young females, preferably ages 11-12, who are not yet sexually active and hence not already infected with HPV, though it has been approved by the FDA for all females ages 9-26. In clinical trials for the 16-26 year old age group, Gardasil was virtually 100 percent effective for five years against the four strains of HPV that it targets (there are over 100 strains of HPV). Yet parents did not rush to get their daughters vaccinated.

Aside from safety, effectiveness and cost issues, some parents and public health officials had additional concerns:

1) Efficacy -- while the vaccine does protect against HPV-16 and HPV-18 (the strains that cause 70% of cervical cancer), by so doing the vaccine may be unleashing other HPV strains which can infect the woman -- thus, the ultimate efficacy of the vaccine against all HPV infections and, ultimately, against cervical cancer may be less than the initial studies indicated;

2) Misallocation of Funds -- money to pay for Gardasil as part of the Medicaid program or some other government program would have to come from somewhere, perhaps leading to a reduction in health prevention or treatment of HPV itself. There is an argument that whatever millions are spent on HPV vaccination might be better spent on a more comprehensive STI prevention program, including condom use and more extensive Pap screening.

3) Risk Compensating Behavior -- conservative groups argued, only somewhat disingenuously, that HPV vaccination would inevitably lead to adolescents engaging in more, earlier and unprotected sex, thereby causing more transmission of HPV and other sexually transmitted infections. Vaccinated, and unvaccinated, adolescents might have a reduced fear of contracting HPV, and might thus engage in more and riskier sex. This is known in the public health world as “risk compensation”, and occurs when there is a perceived change (i.e. reduction) in the risk of acquiring a disease or being involved in an accident, for instance with drivers with seat belts and air bags driving faster. The fact that there is still a multiplicity of sexually transmitted infections out there (including other HPV strains) that Gardasil does not prevent, and thus that there should be no false sense of immunity, has not dissuade these conservative groups from their campaign. This argument might be, in theory, a valid concern, but remains unproven.