What is the management of Human Papillomavirus (HPV)?

Management of Human Papillomavirus (HPV)

The management of HPV infection requires a comprehensive approach including vaccination for prevention, regular screening for early detection of precancerous lesions, and specific treatments for HPV-related conditions such as genital warts and cervical lesions. 1, 2

Prevention

HPV Vaccination

• Routine HPV vaccination is recommended for females and males aged 11-12 years, though it can start as early as age 9 1
• Catch-up vaccination is recommended for females through age 26 and males through age 21 (through age 26 for MSM and immunocompromised persons) 1, 2
• The nonavalent vaccine (9vHPV) provides protection against HPV types 6,11,16,18,31,33,45,52, and 58, potentially preventing approximately 90% of cervical and other HPV-related cancers 1
• HPV vaccination is most effective when administered before potential exposure to HPV through sexual contact 1, 3

Safe Sexual Practices

• Condom use may reduce the risk for HPV and HPV-associated diseases; studies have demonstrated a 70% reduction in HPV infection when partners used condoms consistently and correctly 1, 2
• Abstaining from sexual activity is the surest way to prevent genital HPV infection 2
• For sexually active individuals, a monogamous relationship with an uninfected partner is the strategy most likely to prevent future genital HPV infections 2

Screening

Cervical Cancer Screening

• All women should have a Pap test for cervical cancer screening within 3 years of beginning sexual activity or by age 21 years, whichever occurs first 1, 2
• Women aged >30 years with three normal consecutive Pap tests should be screened every 2-3 years 1
• HPV testing as an adjunct to routine Pap test may be appropriate in certain populations 2
• Consideration should be given to increasing the screening interval to 3 years if both Pap and HPV testing results are negative in women aged >30 years 2

Anal Cancer Screening

• Data are insufficient to recommend routine anal cancer screening with anal cytology in persons living with HIV/AIDS or HIV-negative MSM 2
• An annual digital anorectal examination may be useful for early detection of anal cancer in high-risk populations 2

Treatment of HPV-Related Conditions

Genital Warts

• Imiquimod cream should be applied 3 times per week to external genital/perianal warts 4
• Treatment should continue until there is total clearance of the genital/perianal warts or for a maximum of 16 weeks 4
• A thin layer of imiquimod cream should be applied to the wart area and rubbed in until the cream is no longer visible 4
• Local skin reactions at the treatment site are common; a rest period of several days may be taken if required by patient discomfort 4
• Imiquimod has no direct antiviral activity but induces cytokines including interferon-α at the treatment site 4
• A new formulation of imiquimod (3.75% cream) is also recommended for AGW treatment 2

Precancerous Lesions

• Treatment options for cervical, vaginal, and vulvar cancer precursors include various local approaches that remove the lesion (e.g., cryotherapy, electrocautery, laser therapy, and surgical excision) 2
• Based on limited existing data, available therapies for HPV-related lesions might reduce but probably do not eliminate infectiousness 2

Special Considerations

HPV and HIV Co-infection

• HPV vaccination is recommended for all HIV-infected males and females in a 3-dose series at 11 or 12 years of age, and for those 13-26 years of age if not previously vaccinated 2
• HIV-infected MSM with HPV infection are at increased risk for anal dysplasia and cancer 2
• If anal cytologic screening (anal Pap smears) is performed and indicates abnormal findings, then high-resolution anoscopy should be performed with biopsy of abnormal areas 2

Psychosocial Management

• When HPV testing is carried out, it should be accompanied by evidence-driven and patient-centered counseling to minimize negative psychosocial outcomes 2
• Education should focus on illness, treatment, symptom burden, and sexual behaviors associated with an increased risk of HPV transmission 2
• Counseling for emotional support can be provided through enhanced coping techniques and delivering resources and information 2

Common Pitfalls and Caveats

• HPV vaccination does not protect against persistent infection, cervical cancer precursor lesions, or genital warts caused by an HPV type that individuals are infected with at the time of vaccination 1
• Neither routine surveillance for HPV infection nor partner notification is useful for HPV prevention 2
• HPV infection is so prevalent that the majority of partners of persons found to have HPV infection are infected already 2
• Most HPV infections are cleared by the immune system and do not result in clinical complications; however, persistent infections with high-risk types can lead to cancer 5, 6
• Smoking has been linked with an increased prevalence of oral HPV infection and is associated with a worse prognosis 2