HPV Vaccine Out of Reach for College Students

A new vaccine that protects against the human papillomavirus (HPV) and the cervical cancer it can cause could be an invaluable contribution to women's health. With 80 percent of women contracting some form of HPV before they turn 50 and 3,700 women dying of cervical cancer every year in the United States alone, the vaccine's "Tell Someone" campaign is about more than selling shots -- it's about saving lives. But for the thousands of women who rely on student insurance for their healthcare costs, the vaccine remains out of reach.

Eight months after the Food and Drug Administration approved the vaccine Gardasil for women and girls between ages 9 and 26, many universities do not cover it under their student health plans. Others do not even stock it at their health centers, leaving many college-aged women worried about how they can best protect themselves against HPV.

Fran Gillespie, a senior at New York University, is one of these women. When she went home for winter break this December, she found out that one of her friends had contracted HPV and developed pre-cancerous cells from the virus. Gillespie, who had never heard of HPV before her friend's experience, made an appointment with her private gynecologist to be immunized -- only to be told that she would have to pay nearly $400 because her NYU student insurance did not cover Gardasil. She cancelled the appointment, deciding to wait until she returned to campus.

"I was sure that NYU could provide the same service," Gillespie said. "And because it's for students, they would offer a rate that students can afford."

But when she called the university health center, she was told that the vaccine was not covered by student insurance, and she would have to pay out of pocket. NYU charges $130 per shot for the three-shot immunization.

"I just don't have that kind of money," Gillespie said. "Health insurance and women's issues are the most basic level that a university should have concerns for."

Gillespie still has not been vaccinated, and says that she plans to "just wait" until her insurance plan is expanded.

Unlike NYU, which does make the vaccine available on campus for students who want to pay out-of-pocket or with private insurance, some colleges do not even offer the vaccine. Virginia's James Madison University, for example, still does not stock Gardasil in their student health center, opting instead to write students a prescription that they can have filled at a local pharmacy.

The Facts About HPV

The most common sexually transmitted infection in the United States, HPV can cause cervical cancer, genital warts, and a series of other health problems. There are 6.2 million new cases of HPV in the United States each year, and 20 million people currently live with the virus. Unlike bacterial STIs such as Chlamydia and gonorrhea, which are easily treatable with antibiotics, the warts associated with HPV are signs of a permanent viral infection -- you can get them removed, but the virus will remain in your system.

While some strains can cause visible genital or anal warts, the virus is often asymptomatic. Men are less likely than women to show signs of most types of HPV infections, and because the virus can be passed on even in the absence of symptoms, people often think they are safe when they are not. Even condoms may not offer total protection against HPV.

Karen (who asked that her real name not be used), a 27-year-old law student, is well aware of how easily the virus can spread -- she contracted HPV from her high school boyfriend, and was diagnosed with genital warts at 16.

"I think I found out about HPV by getting it," she said. "My experience going through it was really awful. This self-imposed stigma that you have is something that no one should have to go through if it's an option to prevent it."

Young women like Karen are at a particularly high risk for contracting HPV. In fact, men and women in their late teens and early 20s are more likely to be infected than any other age group. They are less likely than older people to be permanently partnered and more likely to engage in risky sexual behavior, especially if they never learned the basics about sexual health in school, which is commonly the case in schools that teach abstinence-only sex education.

A vaccine that can prevent genital warts and cervical cancer holds great promise in the college environment -- a place where many young men and women are tasting freedom, forging romantic relationships, and exploring their sexuality.

Public Health Debate

There are hundreds of strains of HPV, most of which are harmless, and about 30 of which can be sexually transmitted. A handful of high-risk HPV types can cause cervical cancer, a disease diagnosed in nearly 10,000 American women every year. The strains that the vaccine covers are responsible for at least 90 percent of genital warts cases and 70 percent of cervical cancers, meaning that Gardasil can prevent most instances of genital warts and cervical cancer -- and studies suggest that these are conservative estimates.

Gardasil is currently approved only for women and girls between the ages of 9 and 26, but may eventually be approved for men and boys as well. It is recommended before the onset of sexual activity, but is still valuable for sexually active young women, even if they already have a form of HPV.

While supporting and widely disseminating a cancer-preventing drug may at first glance seem like a no-brainer, the vaccine has sparked a controversy, with two unlikely allies -- abstinence proponents and Big Pharma skeptics -- raising questions about the vaccine's necessity and whether it should be made mandatory for young girls.

Abstinence proponents argue that HPV is a lifestyle disease, and young women should be taught to withhold sex until marriage instead of simply being inoculated against a sexually transmitted infection.

Many progressives and moderates write off that argument as irrational and out of touch with reality -- after all, more than 95 percent of Americans have sex before their wedding day -- but parent and consumer groups are having greater success in raising eyebrows about Gardasil by questioning drug companies' financial ties to politicians and the vaccine's safety.

After Merck's drug Vioxx was fast-tracked onto the market by the FDA and ended up causing some 100,000 heart attacks (half of them fatal), consumers are hesitant to assume that FDA approval indicates infallible safety. Still, vaccine proponents point out that more than 20,000 women were tested over a period of three and a half years. And making the vaccine mandatory would open up access for lower-income women by allowing shots to be covered by social service programs.

It may take years to hash out the debate on whether to make the vaccine mandatory. In the meantime, many women are choosing to inoculate their daughters, and college-aged women are lining up for the shots.

"The vaccine is extremely important for young women," said Dr. Nancy Jasper, a practicing OB/GYN and Assistant Clinical Professor of Obstetrics and Gynecology at Columbia University. "If someone hasn't been exposed, or even if they had, the likelihood that they've been exposed to all of the major HPVs is very unlikely. Most of the time they only have one. The feeling is that it's well spent money. Because we know that in order to get cervical cancer you have to get HPV. So if you don't get HPV, you're not going to get cervical cancer ... It is essentially 100 percent effective."

Since college-age women in particular face a high risk of infection, many doctors and public health specialists argue that inoculating women on college campuses is a crucial step in getting HPV under control.

"From a public health perspective, the more women who are vaccinated, the more it simply decreases the chain of population through which students can transmit disease," said Dr. Carlo Ciotoli, medical director of the student health center New York University. "Students here average two to three sexual partners annually, and if a woman is vaccinated and she's having sex with someone, she is more likely to not spread it. So there are public health benefits as well, in addition to the individual benefit."

Reasons for the Delay on College Campuses

Since receiving FDA approval and coming onto the market in June 2006, thousands of women and girls have been vaccinated, many of whom have private insurance to cover the cost of the vaccine. College women who rely on student health insurance, and women without insurance of any kind, are not so lucky.

"This [vaccine] came out halfway through the year, and the insurance plan is set out at the beginning of the year," said Ciotoli. "Schools that covered vaccines did cover it; schools like NYU that did not cover vaccines did not."

Many university health plans shy away from covering immunizations, since the majority of their student body enters college already vaccinated for basic diseases like measles, mumps and rubella. Health center administrators work with insurance companies every spring to determine what the student health plans will cover, and the plans are set out well before the start of the new academic year -- and so when Gardasil came out in June, the insurance plans at several universities were not able to cover it. When universities and insurance companies design student insurance programs, they focus on what students demand -- usually, Ciotoli said, things like pharmaceutical benefits and lower prescription drug costs, not vaccinations.

"When we prioritize, it's not usually one of the things that we want to raise the cost of the insurance for. Many students who come in have already had their vaccines so we focus on other issues," he said.

To the credit of many universities, Ciotoli said, several student health centers, including NYU, offered the vaccine nearly as soon as it was available, and have been inoculating students since the beginning of fall semester. Some 500 students have been immunized at NYU this academic year alone. Other schools, like Yale, Berkeley, and the University of Wisconsin, also stocked the vaccine at the beginning of the 2006-2007 school year.

Some schools are looking into different options for making Gardasil and other vaccines more affordable for low-income and under-insured populations, including expanding insurance coverage and partnering with the Department of Health. But significant policy changes are unlikely to be seen until next year.

In the meantime, women like Fran Gillespie will hold out until their student insurance covers HPV immunization -- if it ever does. While she waits, privately-insured women like Gillespie's roommate, Catherine Zack are already able to access the potentially life-saving vaccine.

"I waited a couple months until my insurance covered it," said Zack, 22. "When I was reading material about it, they recommend it for very young girls, and women 18-26 is the last age bracket. How much longer could I wait?"


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