Putting HPV Pain to Paper

During a 2019 trip to Kenya to train peer educators to conduct research on the government’s HIV rapid-test rollout, one trainee told Matthew Thomann how the end-of-life AIDS patients at the care center—which also served human papillomavirus (HPV) patients—were tired of being kept awake all night listening to HPV patients cry, scream and writhe in pain.

Moved by such suffering, the University of Maryland assistant professor of anthropology today is serving on the frontlines of Kenya’s fight against this sexually transmitted infection that first presents as warts, but can progress into various forms of cancer.

Supported by a $40,000 Fulbright Scholar award, Thomann is on a mission to understand typical HPV patient trajectories among Kenyan men who have sex with men (MSM) and transgender women—from those with mild cases healed by topical cream to those who require surgery to remove obstructive anal warts—and also to document how their pain is managed.

“We don’t really talk about pain in the Global South,” said Thomann, who is currently in Nairobi. “Analgesics, morphine, muscle relaxers, basic things we would expect in a post-surgical situation are scant,” and minor conditions that would be dealt with easily in places like the United States progress until they require surgery in Kenya.

Treatment for HPV isn’t easy to come by in Kenya—especially for MSM and transgender women, he said. Because homosexual acts are illegal there, there are few clinicians willing to treat people with anal warts, and many sufferers refuse to seek treatment until the warts intrude on their daily lives.

“Nothing marks you as queer more than having anal warts,” said Thomann. “You can’t just show up to a clinic, a public hospital here, or your pediatrician and say, ‘I am having a problem.’”

As a result, many patients present with necrosis—tissue death—or even sepsis, a potentially deadly reaction to severe infection. Add in the COVID-19 pandemic, which canceled HPV surgeries from early 2020 to January 2022, and Thomann is seeing extreme cases during his overnight observations of patients pre- and post-surgery.

While he waits for the official green light to start conducting interviews with willing patients, Thomann pitches in to help however he can: He prepares high-fiber meals of porridge and vegetables, answers questions about medications, prepares post-surgery salt baths and— perhaps most importantly—helps patients physically and mentally ease into a treatment many of them fear will be agonizing. He also tries to be a friend to those in need, such as by enjoying Kenyan music videos together.

Thomann is set to leave in late June, but said his work won’t stop there. He hopes to develop a better understanding of why marginalized groups in Kenya lack access to painkillers, and looking even further down the road, to help get an HPV vaccine program in place.

The barrier to vaccines is partly one of understanding, he said.

“Just like the U.S., they do have Gardasil, but just like the U.S., Kenya shied away from talking about it as a vaccine against an STI, and [instead] talked about it as a vaccine against cervical cancer,” he said. “There are hundreds, even thousands, of men in Nairobi and beyond that know about these surgeries and know what anal warts are, but don’t make the connection between these surgeries, HPV, warts and the vaccine.”

Changing mindsets about the HPV vaccine and pain management won’t be easy, particularly at the government level, but he said it could be life-changing for many.

“People handle pain differently, they express pain differently, but we all feel it,” he said.