Krishnan SS. The HPV vaccine controversy: Sex, cancer, god and politics: a guide for parents, women, men and teenagers. Connecticut (USA): Praeger Publishers;2008. 230p ISBN: 978-0-313-35011-5.

In 2006, the United States’ Advisory Committee on Immunisation Practices unanimously recommended vaccination against the Human Papilloma Virus (HPV) to all 11-12 year old girls in that country. Since then, the HPV vaccine has been riddled with controversies. The provocative title of the book under review is definitely apt: sex, cancer, religion and politics all have their say in this new battle between science, morality and religious views. The author is a gynaecologist and family practice physician based in the USA and is a staff physician at Columbia University’s Barnard College Health Services. As the title suggests, the book acts as a guide and educates the reader on various aspects of HPV, HPV infection and HPV vaccination and also identifies a number of cultural and ethical issues associated with the infection and vaccination.

The book begins by giving the reader basic information about the virus, HPV infection, the tests and vaccination. The author explains why proponents of the vaccine think that opposing the vaccine on the pretext that it will promote sexual promiscuity is like opposing a vaccine for lung cancer on the argument that it will promote smoking. The author then moves on to the moral, political and financial reasons put forth by the opponents of the vaccine.

A good part of the book discusses HPV and gives a detailed description of the virus and the different conditions caused by the virus including cervical cancer. The second, third and fourth chapters provide detailed descriptions of the virology, epidemiological and clinical characteristics, modes of transmission, testing for the disease and risk factors of the disease. Though useful, the highly technical information in this section might discourage the average reader. It ends with some thought-provoking questions regarding the relevance of a vaccine for educated, health conscious women who have regular access to cervical cancer screening. She also raises questions regarding access to vaccination to all sections of the population, benefits of the vaccine other than cervical cancer prevention and the significance of vaccination in the fight against a sexually transmitted disease.

The book then discusses the psychological impact of HPV infection on patients. This is dealt with in the form of a question-answer session covering the gamut of questions that might come to the mind of a person who learns that s/he is HPV positive. The primary preventive and natural ways to fight the spread of the disease are also given in the chapter.

The next section explains in detail the HPV vaccine − its history, the technology, clinical trials, side effects and precautions, and current recommendations. The author identifies two major disadvantages of the vaccine: its low cost effectiveness and the fact that women from lower socio-economic groups do not have access to it. The author ends with a positive note about the vaccine but also raises questions about its long term effectiveness, the side effects and the fact that it works best only against HPV strains 16 and 18.

The author then focuses on the "unsolved half of the equation"- HPV in males. She stresses the importance of increasing awareness about the disease among men and addressing the "elusive male factor" and suggests that it will help to shift some burden of disease prevention from women. She concludes the chapter with the observation that addressing the "elusive male factor" will be a significant step in the fight against HPV.

The next chapter answers questions raised by high school and college youth, presenting the subject in a way that is comprehensible to that age group. The writer then probes the issue from a parents’ perspective and explains the importance of social and cultural acceptance of the vaccine if it has to become successful. She explains that HPV vaccination can be used as an opportunity by parents to provide behavioural guidance to their children in advance so that they are better equipped with knowledge before their sexual debut. She also points out that parents find it more sensible if their children are vaccinated against a sexually transmitted disease at a later age, when they are close to their sexual debut rather than at 9-12 years when they are not even thinking about sex – or at least parents believe that their children are not thinking about sex. The major ethical issues regarding making the vaccine compulsory are also discussed in this section. She points out that even though mandates are introduced to protect public health, legislation to make the HPV vaccine mandatory in the US backfired as parents raised safety and ethical concerns regarding the vaccine; parents felt that the government should restrict its role to that of the provider of science and should not interfere with parents’ freedom of choice. It would be premature to make the vaccine mandatory without taking into account factors like its long term effectiveness, cost effectiveness and side effects.

The author then moves on to the global challenge of HPV infection and explains how competing healthcare needs, poverty, poor healthcare services and cultural barriers are the biggest obstacles in the fight against HPV infections in developing countries. She refers to India, which, in spite of having 20% of the global load of cervical cancer, conducts only a few million Pap smears annually. She also cites clinical studies which predict a reduction of 70% to 80% in the cervical cancer burden with vaccination in developing countries where women carry the real burden of HPV infections. But the prediction will come true and maximum benefit from vaccination will happen only when the HPV vaccination programme reaches those women who unfortunately do not have access to even basic healthcare services, forget HPV vaccination. As she points out, in a country like India, people are bothered more about the vaccine’s affordability and availability than whether to administer it to young people before their sexual debut. The book ends with the story of a woman from India whose life was saved by timely screening and with the hope that HPV vaccination will increase awareness and will help women fight the disease. The tragedy is that Indian women do not even receive cervical cancer screening. In such a situation one can only wonder about the significance of HPV vaccination in India.

India has her own share of controversies linked to the HPV vaccine. Concerns have been raised about the vaccine’s safety and cost-effectiveness as well as the significance of an expensive programme when people’s basic healthcare needs are not met, Questions were also asked about a pilot vaccination programme in Andhra Pradesh and Gujarat: the programme was conducted among vulnerable sections who may not have been able to give informed consent.

The book might be a disappointment for those looking for insights regarding the controversy surrounding HPV vaccine trials in India. India has a different set of concerns and issues than those being raised in the book. Nevertheless the book provides valuable technical knowledge which can help parents as well as doctors take a stand regarding HPV vaccination. Despite the technical nature of the book, it can serve as an excellent referral book for students and the general public.