What are the management recommendations for a patient with a positive Human Papillomavirus (HPV) test on a Pap (Papanicolaou) smear?

Management Recommendations for Positive HPV Test on Pap Smear

Management of a positive HPV test on Pap smear should follow a risk-based approach, with decisions guided by HPV type, cytology results, and patient history to reduce morbidity and mortality from cervical cancer.

Initial Management Based on HPV and Cytology Results

• For HPV-positive results with normal cytology (NILM):

  • If this is the first positive HPV test, repeat HPV testing with or without concurrent Pap test in 1 year 1
  • If this is a second consecutive positive HPV test (persistent infection), immediate colposcopy is recommended regardless of previous Pap test results 1
  • If HPV genotyping is positive for types 16 or 18, immediate colposcopy is recommended even with normal cytology due to higher cancer risk 1

• For HPV-positive results with abnormal cytology:

  • For ASC-US or LSIL with HPV positive:
    • Immediate colposcopy is generally recommended 1
    • Exception: If patient had negative HPV testing or cotesting within previous 5 years, repeat HPV test with or without Pap test in 1 year may be appropriate 1
  • For ASC-H with HPV positive: Immediate colposcopy or expedited treatment 1
  • For HSIL with HPV positive: Colposcopy or expedited treatment; if HPV 16 positive specifically, expedited treatment is preferred for non-pregnant patients ≥25 years 1

Special Considerations

• HPV 16 is the highest-risk HPV type and requires aggressive management:

  • With HSIL cytology: Expedited treatment is preferred for non-pregnant patients aged ≥25 years 1
  • With other cytology results: Colposcopy is recommended even if cytology is normal 1

• HPV 18 has high association with adenocarcinoma:

  • Colposcopy is recommended in all cases, even with normal cytology 1
  • Endocervical sampling is acceptable at time of colposcopy due to association with adenocarcinoma 1

• For HPV types other than 16/18 with normal cytology:

  • Return in 1 year for repeat testing is recommended in most cases 1

Follow-up After Initial Management

• HPV testing or cotesting is preferred over cytology alone for follow-up after abnormal results 1

  • Negative HPV testing or cotesting is less likely to miss disease than normal cytology alone 1
  • When HPV testing/cotesting is recommended at 3-year intervals, cytology alone should be done annually 1
  • When HPV testing/cotesting is recommended annually, cytology alone should be done every 6 months 1

• After treatment for high-grade precancer:

  • Surveillance should continue for at least 25 years 1
  • Initial testing includes HPV test or cotest at 6,18, and 30 months 1
  • Long-term surveillance includes testing at 3-year intervals if using HPV testing or cotesting, or annual testing if using cytology alone 1

Common Pitfalls and Caveats

• Do not dismiss HPV-positive results with normal cytology, as persistent HPV infection is a significant risk factor for developing cervical cancer 1
• Colposcopy may be warranted regardless of current results if patient has history of high-grade lesions (CIN 2/3, histologic or cytologic HSIL, ASC-H, AGC, or AIS) 1
• Negative HPV test or cotest results only reduce risk sufficiently to defer colposcopy if performed for screening purposes within the last 5 years, not if performed for surveillance of previous abnormal results 1
• The Pap test should not be considered a screening test for other STDs 1
• Clinics that cannot provide colposcopic follow-up should have established referral protocols to ensure patients receive appropriate evaluation and treatment 1

The 2019 ASCCP risk-based management guidelines represent the most current approach, focusing on patient-level risk assessment rather than specific test results alone to guide management decisions 1.