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

HPV Prevention and Treatment

Primary Prevention: Vaccination

HPV vaccination is the cornerstone of prevention and should be administered routinely at age 11-12 years for all adolescents, regardless of sex, with catch-up vaccination through age 26 years for those not previously immunized. 1

Vaccination Schedule and Timing

• Girls aged 11-12 years should receive routine HPV vaccination with 3 doses administered intramuscularly at 0,2, and 6 months (vaccination can begin as early as age 9 years at physician discretion) 1
• Two-dose series is recommended if vaccination is initiated before age 15 years; immunocompromised individuals require three doses regardless of age 2
• Catch-up vaccination is recommended for all individuals aged 13-26 years who have not been previously immunized or completed the full series 1
• The nonavalent vaccine (9vHPV) has been the only vaccine available in the United States since late 2016, protecting against HPV types 6,11,16,18,31,33,45,52, and 58 3

Special Populations Requiring Vaccination

High-risk populations benefit significantly from HPV vaccination and include 1:

• HIV-infected patients through age 26 years
• Men who have sex with men (MSM) through age 26 years
• Solid organ or hematopoietic stem cell transplant recipients aged 9-26 years
• Patients with primary immunodeficiencies or receiving immunosuppressive/biological treatments
• Patients with recurrent respiratory papillomatosis
• Women with precancerous cervical lesions (vaccination still beneficial despite existing infection)

Vaccination in Previously Sexually Active Individuals

Sexually active individuals should still receive HPV vaccination, as most are unlikely to have been infected with all vaccine-type HPVs. 1 The vaccine can be administered to patients with abnormal Pap test results, those who are breastfeeding, or immunocompromised individuals 1. However, vaccination does not alter the outcome of established HPV infections caused by vaccine types 1.

Contraindications and Precautions

• Absolute contraindication: History of immediate hypersensitivity to yeast or any vaccine component 1, 4
• Defer vaccination in patients with moderate or severe acute illness 4
• Not recommended during pregnancy: If pregnancy occurs during the vaccination series, postpone subsequent doses until after delivery (report pregnancies to registry at 1-800-986-8999) 1
• Syncope precaution: Have vaccine recipients sit or lie down for 15 minutes after administration, as syncope can occur in adolescents 1, 4

Secondary Prevention: Screening

Regular cervical cancer screening with Pap testing remains essential even for vaccinated individuals, as vaccines do not protect against all high-risk HPV types. 1

Screening Recommendations

• Initiate screening within 3 years of beginning sexual activity or by age 21 years, whichever occurs first 1
• Women aged <30 years: Annual screening recommended by ACOG; annual or biennial screening depending on conventional vs. liquid-based cytology per ACS 1
• Women aged ≥30 years with three consecutive normal Pap tests: Screen every 2-3 years 1
• HPV DNA testing can be used as an adjunct to Pap screening in women aged >30 years; if both tests are negative, rescreening interval extends to every 3 years 1
• Triage of equivocal results: HPV DNA testing is recommended for women with ASC-US Pap test results 1

Behavioral Prevention Strategies

Consistent and correct condom use reduces HPV transmission risk by approximately 70%, though it does not provide complete protection. 1

• Abstinence from any genital contact is the only method to completely prevent genital HPV infection 1
• Monogamous relationships with an uninfected partner reduce future infection risk 1
• Condoms and dental dams may decrease viral spread, though skin not covered by barriers remains vulnerable to infection 1, 2
• Partner notification is not recommended: Most partners of HPV-infected individuals are already infected, and no specific prevention strategies exist for partners 1

Treatment Approaches

HPV infections themselves are not treated; treatment is directed exclusively at HPV-associated lesions, as the virus cannot be eradicated once infection is established. 1

Treatment Modalities for HPV-Associated Lesions

• Genital warts: Treated with local removal procedures (cryotherapy, electrocautery, laser therapy, surgical excision) or topical pharmacologic agents 1
• Cervical, vaginal, and vulvar precancerous lesions: Managed with local approaches including cryotherapy, electrocautery, laser therapy, and surgical excision 1
• Spontaneous regression: 20-30% of anogenital warts regress without treatment 1
• Recurrence rates: Approximately 30% of genital warts recur regardless of whether clearance was spontaneous or treatment-induced 1

Important Treatment Caveats

Available therapies for HPV-related lesions might reduce but probably do not eliminate infectiousness 1. Most HPV infections (approximately 90%) in healthy women are transient and resolve spontaneously within 2 years without intervention 1. Persistent infection occurs in only 10% of infected individuals, with 1% developing neoplastic lesions 1.

Vaccine Impact and Effectiveness

Real-world data demonstrate substantial vaccine impact: from the prevaccine era to 2015-2018, 4vHPV-type prevalence decreased by 88% among females aged 14-19 years and 81% among those aged 20-24 years 3. Significant declines were observed even among unvaccinated females (87% reduction in 14-19 year-olds, 65% in 20-24 year-olds), suggesting herd immunity effects 3.