What are the treatment options for a patient with a positive Human Papillomavirus (HPV) test result?

Management of Positive HPV Test Results

For patients with a positive HPV test result, management should follow a risk-based approach with specific interventions determined by HPV type, cytology results, and patient history, with colposcopy recommended for high-risk findings and surveillance for lower-risk scenarios. 1

Initial Management Based on HPV Type and Cytology

HPV 16 or 18 Positive

• Colposcopy is recommended in all cases, even if cytology is normal, due to the high association with cancer 1
• For HPV 18 specifically, endocervical sampling is acceptable at the time of colposcopy due to its association with adenocarcinoma 1, 2
• For HPV 16 (highest-risk type) with HSIL cytology, expedited treatment should be considered 1

Other High-Risk HPV Types (not 16/18)

• If cytology is normal, return in 1 year is recommended 1
• If cytology shows abnormalities (ASC-US, LSIL, etc.), management depends on the specific findings:
  • For minimally abnormal results preceded by negative screening within 5 years, follow-up in 1 year instead of immediate colposcopy 1
  • For other abnormal cytology results, colposcopy is typically recommended 1

Follow-Up Protocols

After Initial Positive HPV Test

• HPV testing or cotesting is preferred over cytology testing alone for follow-up 1
• If initial management was follow-up at 1 year, colposcopy is warranted if cytology is abnormal or HPV test remains positive at the follow-up visit 1

After Colposcopy or Treatment

• After treatment for high-grade precancer, surveillance should continue for at least 25 years 1
• Initial post-treatment 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

Special Considerations

For High-Risk Findings

• For patients with current precancer risks of 25-59% (e.g., high-grade cytology with positive HPV), management consists of colposcopy with biopsy or excisional treatment 3
• For those with current precancer risks of 60% or more (e.g., HPV-16-positive HSIL), proceeding directly to excisional treatment is preferred 3

For Low-Risk Findings

• For patients with precancer risks <4%, repeat HPV testing is recommended in 1,3, or 5 years depending on 5-year precancer risk 3
• For patients with precancer risks of 4-24% (e.g., ASC-US or LSIL with positive HPV), colposcopy is recommended 3

Treatment Options for HPV-Related Conditions

For Genital Warts

• Topical treatments include:
  • Imiquimod cream, which induces cytokines and decreases HPV DNA at the treatment site 4
  • Podofilox solution, which has shown clearance of warts in clinical studies 5
• Ablative or excisional procedures may be needed for persistent or extensive lesions 6

For Cervical Precancers

• For CIN 1 or less, repeat HPV testing with or without Pap test in 1 year is recommended 2
• For CIN 2+ (moderate or severe dysplasia), treatment options include ablative or excisional procedures 2

Common Pitfalls to Avoid

• Do not delay colposcopy for HPV 16/18-positive results, regardless of cytology findings 2
• Do not overlook endocervical sampling when HPV 18 is detected 2
• HPV testing should not be performed in the following situations:
  • Deciding whether to vaccinate against HPV
  • Testing for low-risk HPV types (e.g., types 6 and 11)
  • Providing care to persons with genital warts or their partners
  • Testing persons aged <25 years as part of routine screening
  • Testing oral or anal specimens 1

Prevention Strategies

• HPV vaccination is the primary method of prevention, ideally administered at 11 or 12 years of age 7
• Use of condoms and dental dams may decrease spread of the virus 7
• Regular screening according to age-appropriate guidelines is essential for early detection 3