Sexually Transmitted Diseases:
Disclosure of Genital Human Papillomavirus Infection to Female Sex Partners by Young Men
Arima, Yuzo PhD*; Winer, Rachel L. PhD†; Kurth, Ann E. PhD‡; Martin, Diane P. PhD§; Hughes, James P. PhD¶; Stern, Michael E. MN, ARNP†; Feng, Qinghua PhD‖; Kiviat, Nancy B. PhD‖; Koutsky, Laura A. PhD†
From the *Emerging Disease Surveillance and Response Unit, Division of Health Security and Emergencies, World Health Organization Regional Office for the Western Pacific, Manila, Philippines; †Research Group, Department of Epidemiology, University of Washington, Seattle, WA; ‡College of Nursing and Director, Global Health Initiatives, New York University, New York, NY; Departments of §Health Services, ¶Biostatistics, ‖Pathology, Harborview Medical Center, University of Washington, Seattle, WA
Correspondence: Yuzo Arima, PhD, Division of Health Security and Emergencies, World Health Organization, Western Pacific Regional Office, Emerging Disease Surveillance and Response Unit, P.O. Box 2932 (United Nations Avenue), 1000 Manila, Philippines. E-mail: email@example.com.
Received for publication August 23, 2011, and accepted March 8, 2012.
A survey was administered to male university students who tested positive for high-risk human papillomavirus. Disclosure was more likely in men with fewer partners, in main partnerships, and in longer partnerships. Disclosure was associated with discussing the Pap test/human papillomavirus vaccine with female partners and not associated with a worsening relationship.
Genital human papillomavirus (HPV) is one of the most common sexually transmitted infections (STIs), with several types considered high-risk (HR) for cervical cancer. As men transmit HPV to their female sex partners, it is important to include men in prevention strategies for reducing HR-HPV and cervical cancer.1 Although the US Food and Drug Administration approved the use of HPV vaccine for men aged 9 to 26 years, testing men for HR-HPV is considered “off-label” and is not recommended by national medical organizations. However, a 2004 survey found that 62% of a representative sample of clinicians who used HPV DNA tests and saw male patients reported having used HPV tests for men.2 However, it is currently unknown whether men who find out their HR-HPV DNA status are communicating this knowledge to their partners. In light of apparent male testing and limited research in HPV disclosure, we developed a survey on HR-HPV disclosure by young men to their female sex partners to determine (1) factors associated with self-reported disclosure of incident HR-HPV infection, (2) whether disclosure is associated with discussion of Pap test/HPV vaccine, and (3) whether disclosure is associated with a perceived change in relationship.
From June 2003 to April 2010, we conducted a longitudinal HPV study of male university students in Seattle, United States. Recruitment and data collection methods have been described elsewhere.3 Male university students were eligible if they were aged 18 to 21 years, were residents of Washington state, were in good health, were able to provide informed consent, and reported a history of sexual activity with a female. At each triannual study visit, the research clinician performed a genital examination and collected penile, scrotal, and distal urinary tract cell specimens. PCR-based methods were used to detect HR-HPV types (HPV16/18/26/31/33/35/39/45/51/52/53/56/58/59/66/68/73/82 and IS39) and uncertain cancer potential types (HPV62/64/67/69/71/83/84).
A brief, self-administered, close-ended survey on disclosure was developed based on our earlier male perspectives survey1 and other STI disclosure/notification surveys4–6 (Bita Amani, personal communication). Assessment was done at the partnership level, with information collected on up to the 5 most recent female sex partners in the past year. At each visit, men were notified of their HPV genotyping results from the prior visit's sampling. During notification, the clinician provided counseling and HPV informational material, and explained that certain types are associated with cervical cancer risk without encouraging disclosure. From January 2008 to January 2010, those who had an incident HR-HPV infection (including HPV types of uncertain cancer potential) were asked, at the subsequent visit following notification, to participate in a confidential online survey. Incident HR-HPV infection was defined as the first detection of a specific HR or uncertain cancer potential type following a prior negative test for that type. Subjects were allowed to take the survey more than once at subsequent visits for each additional incident HR-HPV infection.
Statistical analyses were done using Stata 10.0 (Stata Corp., College Station, TX). The generalized linear model (binomial family, log-link) with binary outcomes was used to obtain relative risks and 95% confidence intervals. We accounted for nonindependence among partners of the same subject and subjects who participated in the survey more than once using the sandwich variance estimator. To assess whether the disclosure was associated with Pap test/HPV vaccine discussion, HR-HPV disclosers were asked whether they had such discussion after disclosure, and HR-HPV nondisclosers were asked about such discussion after HR-HPV notification. Similarly, for any perceived relationship change, we asked whether the subject had such change after disclosure among disclosers and after notification among nondisclosers. Variables significantly associated with disclosure in univariate analyses were included in a multivariate model.
Eighty-one (94%) of 86 eligible men with an incident HR-HPV infection completed the survey contributing 264 partner-specific observations. Fifty-five men took the survey once, 20 men twice, 5 men 3 times, and 1 man 4 times. Representative of this student population, subjects were predominantly white (Table 1). Disclosure was reported in 81 of 264 (31%) partnerships, with 43 of 81 (53%) partnerships disclosing right after and 18 of 81 (22%) disclosing within the first week of notification. Promoters of disclosure centered on themes of honesty and caring (Table 2), whereas perceived disincentives were diverse (Table 3). Disclosure was associated with main partnership type, longer partnership length, fewer partners (Table 4), and with an increased likelihood of discussing Pap tests/HPV vaccine (Table 5). After accounting for confounding, disclosure was not significantly associated with relationship change (Table 5). Among subjects who reported a change in relationship after disclosure, 9 of 24 (38%) improved relationships attributed it to disclosure, whereas 2 of 12 (17%) worsened relationships attributed it to disclosure. Negative responses after disclosure were uncommon (Table 6), and only 7 of 81 (9%) disclosures reportedly led to an argument. After disclosure, when asked whether their partners asked them about their past sex history, recent sex partners, their condom use, or the HPV vaccine, the respective proportions were 40%, 31%, 20%, and 26%, respectively.
To date, few studies have assessed disclosure of HPV infection. Although other HPV disclosure studies6–9 have reported disclosure to a partner ranging from 39% to 65%, this study found that young men disclosed their HPV status to approximately one-third of their recent female partners; the lower disclosure proportion may be because of the assessment of all partners during the past year. Similar to our findings, a recent study on disclosure of genital warts reported that longer and closer relationships were most predictive of disclosure.10 Partnerships with strong emotional ties in general seem to be important in STI disclosure,11–14 and consistent with the literature, we found that honesty and caring for the partner were important promoters of HR-HPV disclosure,6,10 whereas embarrassment6,10 and presumed protection from condom use10 were commonly reported disincentives. We did not find fear of rejection6 or stigma perception10 to be barriers, and blame15 was not a major reason for disclosure.
We previously found that sexually active men diagnosed with HPV intended to encourage their partners to obtain Pap tests,1 and the current study results support these findings. In addition, we found that disclosure was associated with HPV vaccine discussion, an activity that is likely to promote education about the risks and benefits of HPV immunization. Still, there has been concern that STI disclosure/notification could dissolve relationships and lead the infected individual to form new partnerships, leading to greater transmission.11 Our results, however, agree with the limited number of HPV studies that did not find disclosure to be associated with negative relationship outcomes.6,10,16,17 The majority of disclosers reported that their partners were supportive, and only a low proportion of disclosers attributed a worsening relationship to disclosure. A recent study of genital warts also found that partner response after disclosure was more supportive than disclosers had expected10; with increasing HPV awareness,10 women may have become more normalized to HPV.8 Moreover, these findings broadly agree with other STI studies that found that disclosure/notification does not appear to have negative relationship outcomes.11,18,19 Indeed, partnership dissolution rates in general are already high in the United States,20,21 and STI disclosure may have less influence on partnerships than imagined.11
This study has important limitations. As subjects were college students, the results may not be generalizable to other heterosexual men. However, as approximately 65% of US males who complete high school enroll in college the year after graduation,22 our findings may have important implications for this large segment of the population. Although overreporting of disclosure1 might have occurred, bias was minimized by use of a self-administered online survey. Moreover, among the 71“disclosing” men who reported intercourse, only 18 (25%) reported disclosing their HR-HPV infection before the act. Although such “delayed disclosure”5 was not ideal, it reflected the potentially limited social desirability bias operating in this survey (perhaps partly because subjects were aware that disclosure is not recommended).
It is possible that disclosers were self-selectors who did not expect a negative partner response.10 However, prior studies have reported disclosure to be unassociated with anticipated negative consequences,10,23 and we did not find fear of rejection or loss of relationship to be important reasons for nondisclosure. Importantly, we found the effect of disclosure on relationship change to be similar for both main and casual partnerships, and we controlled for partnership type in the analysis. Lack of adjustment for partnership type has been a limitation in previous studies,11,18,24 as subjects are more likely to disclose to main partners.24 One HIV disclosure study that assessed those only in main partnerships found that disclosers were indeed less likely to experience partnership dissolution than nondisclosers.19
This study provides the first data on the correlates and outcomes of male-to-female disclosure of HR-HPV infection. Disclosure did not lead to a perceived worsening relationship, and as disclosers were more likely to discuss the Pap test/HPV vaccine with their partners than nondisclosers, disclosure might be associated with public health benefits that derive from discussions about preventing HPV infections and cervical cancer.
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