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Managing HPV A New Era in Patient Care

• Presented By
• Association of Reproductive Health Professionals
  www.arhp.org
• Planned Parenthood Federation of America
• www.ppfa.org

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Expert Medical Advisory Committee

• Nancy R. Berman, MSN, APRN, BC
• Barbara Clark, MPAS, PA-C
• Don Downing, RPh
• Francisco Garcia, MD, MPH
• Sherri Sheinfeld Gorin, PhD
• Richard Guido, MD
• Julie Hibben, LMSW, CPSI

Required Slide
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Expert Medical Advisory Committee (Continued)

• Mary M. Rubin, RNC, PhD, CRNP
• Marie Savard, MD
• Anafidelia Tavares, MD, MPH
• Maria Trent, MD, MPH
• Jeffrey Waldman, MD
• Thomas C. Wright, Jr, MD

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Module 2 HPV and External Genital Warts
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Learning Objectives

• Identify the natural history of external genital
  warts (EGW)
• Discuss provider- and patient-applied EGW
  treatment modalities
• Identify factors to consider when selecting EGW
  treatment

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Impact External Genital Warts

• 90 caused by HPV types 6 and 11
• Affects 1 of sexually active women age 18 to 45
• 500,000 to 1 million cases annually
• 240,000 initial office visits
• 1/3 of all STI dollars
• 167 million annually

Chesson HW et al. Perspect Sex Reprod Health.
2004 CDC. HPV Information for Clinicians. 2006.
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External Genital Warts (EGW)

• Natural history
• Resolve without treatment (about 20)
• Remain unchanged
• Increase in size or number
• Follow published guidelines for cervical cancer
  screening in women with EGW

CDC. Human Papillomavirus HPV Information for
Clinicians. 2006 Koutsky K. Am J Med. 1997
Chesson HW. Perspect Sex Reprod Health. 2004
ASCCP. Modern Colposcopy. 2004.
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HPV Types in External Genital Warts
Koutsky L. Am J Med. 1997.
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Diagnosing External Genital Warts

• Visual appearance
• of lesions
• Can be confirmed by biopsy if needed
• HPV tests are not
• indicated

CDC. Human Papillomavirus HPV Information for
Clinicians. 2006. Photograph courtesy of Dr.
Thomas C. Wright, Jr. MD
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Treating External Genital Warts

• Primary goal removal for cosmetic reasons
• Unknown impact on reducing infectivity
• Treatment successful in most cases
• Recurrences are common
• Patient and provider-applied treatments are
  available

CDC. Human Papillomavirus HPV Information for
Clinicians. 2006.
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EGW Treatment Modalities

• Provider delivered
• Trichloroacetic acid/bichloroacetic acid
• Cryotherapy (liquid nitrogen and other methods)
• Excision, laser ablation, or electrosurgery
• Patient applied
• Imiquimod (Aldara) 5 Cream
• Podophyllotoxin (Condylox) 0.5 gel

CDC. Human Papillomavirus HPV Information for
Clinicians. 2006.
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Selecting EGW Treatment

• Based on size, number, location of lesions
• Consider invasiveness
• Consider cost
• Patient preference important

CDC. Human Papillomavirus HPV Information for
Clinicians. 2006.
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EGW Treatment Algorithm

• Based on a retrospective chart review of 100
  charts from 5 Planned Parenthood Federation of
  America clinic sites in the US
• Evaluated economic impact of various treatment
  modalities

more
Planned Parenthood Federation of America.
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EGW Treatment Algorithm (Continued)

• Key finding 47 of clinic resources were spent
  on the 26 of patients who required 4 or more
  clinic visits before clearance of EGW
• Algorithm developed for most efficiently use of
  clinic resources in treating EGW

Planned Parenthood Federation of America.
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PPFA EGW Treatment Algorithm
Imiqumod w/ Education Materials
EGW atient
Treatment Completed
Patient w/ EGW
1st time EGW Patient
Multiple Locations
NO
Recurrent EGW Patient
YES
NO
Single location of lesions?
Treat w/ TCA/ Cryo
Cleared in YES
Planned Parenthood Federation of America.
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Expert Medical Advisory Committee
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Nancy R. Berman, MSN, APRN, BC Northwest
Internal Medicine Associates Southfield, MI
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Barbara Clark, MPAS, PA-C Knox OB/GYN,
Ltd. Galesburg, IL
Don Downing, RPh Clinical Associate Professor,
Department of Pharmacy Institute for Innovative
Pharmacy Practice University of Washington School
of Pharmacy Seattle, WA
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Expert Medical Advisory Committee (Continued)
Francisco Garcia, MD, MPH (Chair) Associate
Professor Director, Division of Gynecology
University of Arizona Tuscon, AZ
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Sherri Sheinfeld Gorin, PhD Associate Professor
of Health and Social Behavior Columbia
University New York, NY
Richard Guido, MD Associate Professor of
Obstetrics/Gynecology Reproductive
Services University of Pittsburgh Pittsburgh, PA
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Expert Medical Advisory Committee (Continued)
Julie Hibben, LMSW, CPSI Director of Education
Community Outreach Planned Parenthood of Greater
Iowa Des Moines, IA
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Marie Savard, MD Author and Private Practice
Internal Medicine and Womens Health Wynnewood,
PA
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Mary M. Rubin, RNC, PhD, CRNP Associate Clinical
Professor School of Nursing Gyn Oncology Clinical
Research Coordinator University of California San
Francisco San Francisco, CA
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Expert Medical Advisory Committee (Continued)
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Anafidelia Tavares, MD, MPH Director, The ISIS
Project The Balm in Gilead, Inc New York, NY
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Maria Trent, MD, MPH Assistant Professor,
General Pediatrics and Adolescent Medicine Johns
Hopkins University Hospital Baltimore, MD
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Jeff Waldman, MD Senior Director, Clinical
Services and Medical Education Planned Parenthood
Federation of America New York, NY
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Expert Medical Advisory Committee (Continued)
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Thomas C. Wright, Jr, MD Pathology Columbia
University New York, NY
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