A prominent New York City healthcare provider and activist has taken aim at the U.S. Centers for Disease Control for posting misinformation on its website regarding the dangers of human papillomavirus (HPV) infection in men.

Jeff Huyett, a nurse practitioner who works at a Manhattan medical office that specializes in the diagnosis and care of HPV-related anal disease, charges in a May 9th letter to the CDC that the misinformation is both “shocking” and “exhibits a blatant level of homophobia.” His grievances focus on a fact sheet, last reviewed by the CDC in March 2006 (http://www.cdc.gov/std/hpv/STDFact-HPV-and-men.htm).

Anal HPV Infection: What are the Risks?

One of Huyett’s primary concerns is the CDC’s minimizing of risks associated with HPV infection in men. According to the fact sheet, “there is no clear benefit to knowing you have this virus – since HPV in unlikely to affect your health and cannot be treated.” But according to Huyett, HPV can and does affect the health of thousands of men, especially those living with HIV.

It is true that anal cancer, which can be caused by HPV, is fairly rare.  Its incidence in the general population is less than one per 100,000 people and is one-tenth the current rate of cervical cancer in the United States.  However, when evaluating the incidence of anal cancer among specific populations, more startling numbers come into play.  In a 1987 report, it was estimated that incidence of anal cancer among HIV-negative men who engage in receptive anal intercourse with other men was up to 35/100,000 – a rate on a par with the incidence of cervical cancer before routine Pap smears were initiated in the 1940s.

Even more troubling is the incidence rate among HIV-positive MSM.  During the late 1980s, the incidence of anal cancer among gay men with AIDS was suggested in one report to be twice that of men of the same age, race, and sexual orientation in the years before AIDS (1975 to 1979). In other words, the incidence of anal cancer may be more than 70 of every 100,000 HIV-infected men who have a history of receptive anal intercourse with other men.

Also of concern are the high numbers of MSM with anal dysplasia – lesions that can lead to anal cancer. In one San Francisco cohort consisting of more than 600 MSM, anal dysplasia was found in 36% of the HIV-positive men and 7% of the HIV-negative men.

According to Dr. Joel Palefsky of the University of California, San Francisco, these and other observations “would suggest that we should be mounting all-out campaigns to educate people around these issues and immediately implement screening and treatment programs to prevent anal cancer, modeled after the highly successful programs to prevent cervical cancer.”

Screening for Anal HPV Infection and Dysplasia

As is clear in the fact sheet, implementing screening and treatment programs to prevent anal cancer does not appear to be a priority at the CDC. Text in the fact sheet currently reads:

“There are currently no tests approved to detect early evidence of HPV-associated cancers in men, as there are for women (Pap tests). Nonetheless, since anal cancer is more common in gay, bisexual, and HIV-positive men, some experts recommend routine anal Pap tests for those populations. The anal Pap test is used to find abnormal cells in the anus (caused by HPV) that could turn into cancer over time. However, it is not yet clear that finding and removing abnormal cells from the anus will effectively prevent anal cancer from developing in the future. CDC does not recommend anal cancer screening.”

According to Huyett, the information about anal Pap smears is not true. “The test is a cytological test that can be utilized on any cells of mucous membranes,” he wrote. “It can be used in the bronchial tubes, esophagus, or, even, the anus. To say that this test isn’t approved to evaluate for tissue and cell changes that would indicate cancerous or pre-cancerous tissue in the anus is a complete lie! (The test that is not approved for men is the Digene Hybrid Capture swab for HPV testing.)”

In another fact sheet regarding genital HPV infection on the CDC website, focusing on the value of Pap smears to detect cervical HPV disease, it states:

“A Pap test can detect pre-cancerous and cancerous cells on the cervix. Regular Pap testing and careful medical follow-up, with treatment if necessary, can help ensure that pre-cancerous changes in the cervix caused by HPV infection do not develop into life threatening cervical cancer. The Pap test used in U.S. cervical cancer screening programs is responsible for greatly reducing deaths from cervical cancer. For 2004, the American Cancer Society estimates that about 10,520 women will develop invasive cervical cancer and about 3,900 women will die from this disease. Most women who develop invasive cervical cancer have not had regular cervical cancer screening.”

Huyett notes that, in the United States, “it would be considered malpractice if a woman developed cervical cancer due to her provider’s negligence to screen her cervix with a Pap smear. The same kind of clinical responsibility should be given clinicians to screen high-risk men and women for changes in the squamocolumnar cells of the anus in order to prevent cancer.”

In concluding his letter, Huyett voices his confusion as to why the CDC does not advocate for anal screening of MSM. “Your strident recommendations for Pap screening in women make your recommendations for gay and bisexual men look paltry,” he says. “This substandard care shows an extreme homophobia in its lack of health care parity and prevention for gay and bisexual men or any U.S. citizen at risk due to their sex practices. Gay and bisexual men are actually at higher risk, statistically, for an HPV-related cancer than the average American woman who gets an annual opportunity via Pap screening, to insure her health. You reinforce this notion of poor preventative care, then, when you say, ”CDC does not recommend anal cancer screening."