What are the treatment and prevention options for Human Papillomavirus (HPV)?

Human Papillomavirus (HPV): Treatment and Prevention

Prevention Through Vaccination

Routine HPV vaccination should be administered to all adolescents at age 11-12 years (can start as early as age 9), regardless of sex, using the nonavalent vaccine (9vHPV) which prevents approximately 90% of HPV-related cancers. 1, 2

Vaccination Schedule by Population

Primary vaccination targets:

• Females aged 11-26 years: Routine vaccination with bivalent (2vHPV), quadrivalent (4vHPV), or nonavalent (9vHPV) vaccine 1
• Males aged 11-21 years: Routine vaccination with 4vHPV or 9vHPV 1
• Males aged 22-26 years: Vaccination may be administered but is not routinely recommended unless they are MSM or immunocompromised 1

High-risk populations requiring vaccination through age 26:

• Men who have sex with men (MSM) 1
• People living with HIV 1, 2
• Immunocompromised individuals (including transplant recipients, those on immunosuppressive therapy, primary immunodeficiency) 1
• Patients with recurrent respiratory papillomatosis 1
• Women with precancerous cervical lesions 1

Dosing Regimen

• Two-dose series: Recommended if vaccination initiated before age 15 years 3
• Three-dose series: Required for immunocompromised individuals and those starting vaccination at age 15 or older, administered at 0,2, and 6 months 1, 3

Critical Vaccination Considerations

Vaccination should proceed even in these circumstances:

• History of abnormal Pap test results 1
• Known HPV infection or genital warts 1
• While breastfeeding 1
• In immunocompromised patients 1

Contraindication: Pregnancy - defer subsequent doses until after delivery and report exposures to manufacturer registry (1-800-986-8999) 1

Prevention Through Behavioral Measures

Condom use provides significant but incomplete protection:

• Consistent and correct condom use reduces HPV acquisition by approximately 70% in newly sexually active women 1, 2
• Protection is incomplete because HPV can infect skin not covered by condoms 1, 2

Sexual abstinence is the only method providing complete protection from genital HPV infection 1, 2

For sexually active individuals, monogamous relationships with uninfected partners offer the best risk reduction strategy 1, 2

Screening for HPV-Related Disease

Cervical Cancer Screening

All women should initiate Pap testing within 3 years of sexual activity or by age 21 years, whichever comes first 1, 2

Screening intervals:

• Women under 30 years: Annual screening recommended 1
• Women 30 years and older with three consecutive normal Pap tests: Screen every 2-3 years 1, 2
• Women 30 years and older with negative Pap AND negative HPV co-testing: Can extend screening interval to 3 years 1, 2

HPV testing adjuncts:

• HPV DNA testing should be used to triage women with equivocal (ASC-US) Pap results 1
• Co-testing with HPV and Pap is appropriate for women over age 30 1, 2

Anal Cancer Screening

Routine anal cytology screening is NOT recommended even for high-risk populations (HIV-positive individuals, HIV-negative MSM) due to insufficient evidence 2

Annual digital anorectal examination may be useful for early detection in high-risk populations 2

If anal cytology is performed and shows abnormalities, proceed with high-resolution anoscopy and biopsy 2

Treatment of HPV-Related Lesions

HPV infections themselves are not treated - only the resulting lesions receive treatment 1

Treatment Modalities for Precancerous Lesions

Cervical, vaginal, and vulvar precancerous lesions:

• Cryotherapy 1, 2
• Electrocautery 1, 2
• Laser therapy 1, 2
• Surgical excision 1, 2

Treatment for Genital Warts

Topical pharmacologic agents:

• Imiquimod 3.75% cream applied to treatment area 2, 4
• Other topical agents as clinically indicated 1

Ablative procedures:

• Cryotherapy, electrocautery, laser therapy, or surgical excision 1

Important limitation: Available therapies may reduce but probably do not eliminate HPV infectiousness 1

Critical Pitfalls and Caveats

Vaccination does not protect against existing infections: The vaccine cannot clear HPV types already present at time of vaccination and does not treat existing precancerous lesions or genital warts 2

Screening must continue after vaccination: HPV vaccines do not protect against all oncogenic HPV types, so cervical cancer screening recommendations remain unchanged for vaccinated women 1, 2

Partner notification is not useful: HPV infection is so prevalent that most partners of infected individuals are already infected, and no prevention strategies exist for partners 1, 2

Syncope risk in adolescents: Consider having vaccine recipients sit or lie down for 15 minutes after administration 1

Smoking increases risk: Tobacco use is linked to increased oral HPV infection prevalence and worse prognosis for HPV-related cancers 2

Patient Counseling Essentials

Key counseling points for HPV-positive patients:

• HPV is extremely common - most sexually active persons acquire it at some point 1
• Most infections clear spontaneously within 2 years 1
• Detection does not indicate infidelity, as infection can persist asymptomatically for years before detection 1
• No validated test exists for HPV in men 1
• Partners in long-term relationships typically share HPV status 1

Psychosocial support: Counseling should address illness understanding, treatment options, symptom burden, and provide emotional support through coping techniques and resources 2