Human papillomavirus (HPV) is the most common sexually transmitted infection in the world which affects both males and females. It involves a group of viruses known as the human papillomaviruses which constitute the ability to form warts on the skin and genital area. Of particular important, HPV was also shown to cause cancer of the reproductive organs, cervix and throat, in select cases.

HPV variants

There are more than 100 types of HPVs, which are divided into two main groups based on their risk for causing cancer. Low-risk HPV involves those variants which are considered low-risk due to their association with the development of benign, or non-cancerous, warts. Low-risk HPV types include HPV 6 and 11, which are responsible for about 90% of all genital warts. On the other hand, high-risk HPV involves HPV variants associated with an increased risk of developing HPV-related cancers. High-risk HPV types include HPV 16, 18 and 31 among others.

HPV prevalence in the EU

The prevalence of HPV varies widely by age and sex. According to the Centres for Disease Control and Prevention (CDC), based in the USA, about 80% of sexually active people will have HPV at some point in their lives. The highest rates of HPV are found in people in their late teens and early 20s. In Europe, the overall prevalence of HPV is estimated to be around 11%, with higher rates in younger age groups. In Malta, the prevalence of HPV is similar to that of other European countries, with an estimated 10-15% of the population infected with the virus.

Causes and risk factors

As mentioned previously, HPV is caused by the human papillomavirus which is spread through skin-to-skin contact during sexual activity with individuals infected with the virus. Interestingly, HPV has also been noted to spread through sharing of objects exposed to reproductive fluids from the infected individuals.

Several factors can increase the susceptibility of contracting HPV. These include having multiple sexual partners, unprotected sex, a weakened immune system and smoking. Additionally, Human immunodeficiency virus (HIV)-positive individuals are at a higher risk for HPV-related cancers, most likely due to implications that HIV has on the immune system.

Signs and symptoms

HPV infections are common, however, most people's immune systems are able to clear the virus on their own within a few years. It thereby comes to no surprise that many cases of HPV are symptomless, meaning that a person can be infected with the virus and not even know it. In fact, most people who contract HPV, even those with high-risk types of HPV, have a high chance of never developing any symptoms or health problems from the virus.

It's worth mentioning that while most HPV infections are symptomless, the virus can still be spread to others, even if there are no visible symptoms. This is why practicing safe sex, getting vaccinated against HPV and getting regular check-ups with a healthcare provider are all important steps in preventing the spread of the virus and any associated health problems.

In symptomatic cases, however, patients may exhibit genital warts, which are small, bumps on the skin. Genital warts can appear on various areas adjacent to and on the reproductive organs including the cervix and scrotum. They may be flesh-coloured, pink or red and can be flat or raised. Some people with HPV may also develop abnormal cell changes in the cervix, which can lead to cervical cancer.

The relation between HPV and cervical cancer

From the numerous HPV variants, a select number of HPVs can cause changes to the cells in the cervix, which is the lower part of the uterus that connects to the vagina. These changes are known as cervical dysplasia, and they can sometimes develop into cancer if left untreated.

HPV-related cervical cancer usually develops slowly over a period of years and it often doesn't cause any symptoms in the early stages. The virus can infect the cells of the cervix, causing them to grow abnormally and form precancerous lesions. Over time, these precancerous lesions can turn into cancer.

The risk of developing cervical cancer from HPV depends on several factors, including the type of HPV causing the infection. The most common cancer-causing types are HPV 16 and 18, which are responsible for about 70% of all cases of cervical cancer.

According to the World Health Organization (WHO), an estimated 570,000 new cases of cervical cancer are diagnosed each year, and 311,000 women die from the disease. The incidence rate of HPV-related cervical cancer varies by country and region. It is important to note, however, that women who have regular Pap smears, which can detect pre-cancer changes in the cervix, and get vaccinated against HPV are much less likely to develop cervical cancer. If pre-cancer changes are detected, treatment can be administered prior to the transformation to cancer.

Treatment

Currently, there is no cure for HPV, but the infection usually goes away on its own within two years. Despite the lack of disease-specific treatment, there are several treatment options available for any health problems that can arise by the presence of the virus.

Genital warts caused by HPV detection, can be treated with topical medications or procedures to remove such warts including freezing, laser therapy or surgery. While these treatments can remove the warts, they do not cure the underlying HPV infection which does not exclude the reoccurrence of HPV-related warts in the future.

Moreover, in patients whose HPV diagnoses has resulted in the detection of abnormal changes in the cervix, the abnormal cells can be removed through a procedure called a colposcopy. This involves using a special microscope to examine the cervix and remove any abnormal cells. In some cases, more extensive surgery may be needed to remove larger areas of abnormal tissue.

On the other hand, in HPV-related cancer, the treatment will depend on the type and stage of the cancer. Treatment options may include surgery, radiation therapy, chemotherapy or a combination of these. As mentioned earlier, early detection is key in treating HPV-related cancers, so regular screening and check-ups with a healthcare provider are important.

Vaccinations and testing centres in Malta

If you suspect that you have been exposed to a sexually transmitted disease (STD) or sexually transmitted infection (STI) or are looking in doing a routine sexual health check-up, there are several places one can visit.

The GU Clinic is a sexual health clinic run by the government's health services. It provides free and confidential testing and treatment for sexually transmitted infections (STIs), including HPV. You can find the clinic at St Luke's Hospital in Guardamangia. Additionally, Mater Dei Hospital also offers a range of healthcare services, including sexual health testing and treatment. You can make an appointment by contacting the Sexual Health Clinic.

In addition, Malta has a national HPV vaccination programme for girls and boys, which aims to protect against the most common cancer-causing types of HPV. The vaccination is free of charge and is offered to students in Year 8 of primary school, which is around the age of 12-13, regardless of gender.

The HPV vaccine used in Malta protects against nine types of HPV that can cause cancer or genital warts. The vaccine is given in two doses for individuals between nine and 14 years old, with the second dose given six months after the first. The vaccine can also be given to 15-year-olds or above in three doses, however ideally prior to an individual's 25th birthday. The vaccine is safe and effective, with clinical trials showing it to be up to 97% effective at preventing HPV infection.

By vaccinating young people before they become sexually active, the programme aims to protect them from HPV-related health problems later in life. It's important to note that while the HPV vaccine is highly effective, however it does not protect against all types of HPV. It's still important for young people to practise safe sex and get regular check-ups to prevent and detect STIs.

Prof. Renald Blundell is a biochemist and biotechnologist with a special interest in Natural and Alternative medicine. He is a professor at the Faculty of Medicine and Surgery, University of Malta

Desireè Sant is a medical student who has graduated from a Bachelor of Science in Medical Biochemistry and has a keen interest in rare diseases and oncology

Photo: AI-generated images created by Prof. Blundell