What are the prevention and treatment options for Human Papillomavirus (HPV) in individuals, particularly those between 11 and 26 years old?

HPV Prevention and Treatment: Vaccination Guidelines for Ages 11-26

Primary Prevention: Vaccination Recommendations

All individuals aged 11-26 years should receive HPV vaccination, with routine vaccination ideally administered at ages 11-12 years to maximize cancer prevention before sexual exposure. 1

Age-Specific Vaccination Guidelines

Routine Vaccination (Ages 11-12 years):

• Both males and females should receive HPV vaccination starting at age 11-12 years, though vaccination can begin as early as age 9 years 1
• The nonavalent vaccine (9vHPV/Gardasil 9) is currently the only HPV vaccine distributed in the United States and protects against HPV types 6,11,16,18,31,33,45,52, and 58 1
• This vaccine prevents approximately 66% of cervical cancers (HPV 16/18) plus an additional 15% from the five additional high-risk types 1

Catch-Up Vaccination:

• Females aged 13-26 years: Routine vaccination is recommended regardless of sexual activity history, previous abnormal Pap tests, known HPV infection, or presence of genital warts 1
• Males aged 13-21 years: Routine vaccination is recommended 1
• Males aged 22-26 years: Vaccination may be administered, though it is permissive rather than routine 1
• Special populations (MSM, HIV-positive individuals, immunocompromised persons): Routine vaccination is strongly recommended through age 26 years due to higher risk of HPV-related cancers 1

Dosing Schedule

• Two-dose schedule: Recommended for individuals starting vaccination before age 15 years, with doses given at 0 and 6-12 months 2, 3
• Three-dose schedule: Required for individuals aged 15 years and older, or immunocompromised individuals of any age, given at 0,1-2, and 6 months 1, 2
• Minimum intervals if doses given early: 4 weeks between doses 1 and 2, and 12 weeks between doses 2 and 3 1

Vaccination in Special Circumstances

Patients can and should receive HPV vaccination even when:

• They have current genital warts (vaccine protects against other HPV types not yet acquired) 4
• They have abnormal Pap test results 1, 4
• They are breastfeeding 1, 5
• They are immunocompromised (though response may be reduced, the vaccine is safe as it is non-infectious) 1, 5

Critical caveat: The vaccine does not treat existing HPV infections or existing genital warts—it only prevents future infections with vaccine-type HPV strains 4

Contraindications and Precautions

Pregnancy is the primary contraindication:

• HPV vaccination should be delayed until after pregnancy completion 5
• If a woman discovers she is pregnant after starting the vaccine series, the remaining doses should be postponed until after delivery 5
• If a dose was inadvertently given during pregnancy, no specific intervention is needed, but the exposure should be reported to the pregnancy registry at 800-986-8999 5
• Vaccination can be safely administered immediately postpartum, even before hospital discharge 5

Real-World Vaccine Effectiveness

The evidence demonstrates remarkable population-level impact:

• From 2003-2006 (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 6
• Among vaccinated sexually experienced females, 4vHPV-type prevalence decreased by 97% (ages 14-19) and 86% (ages 20-24) 6
• Importantly, unvaccinated females also showed significant declines (87% for ages 14-19,65% for ages 20-24), demonstrating substantial herd protection effects 6

Treatment of HPV-Related Conditions

For genital warts (when present):

• Imiquimod cream can be used topically, though it has no direct antiviral activity and works by inducing local immune responses 7
• Treatment does not prevent recurrence, which commonly occurs especially in the first 3 months 4
• Vaccination should still be offered to patients with genital warts for protection against other HPV types 4

For high-grade anal intraepithelial neoplasia (HGAIN):

• Treatment options include imiquimod, 5-fluorouracil, infrared coagulation, electrocautery, and surgical excision, though recurrence rates range from 25-75% 1
• Insufficient evidence exists to recommend routine anal cancer screening even in high-risk populations (HIV-positive individuals, MSM) 1

Critical Clinical Pearls

• Vaccination is most effective before sexual exposure, but sexually active individuals should still be vaccinated as they are unlikely to have been infected with all vaccine-type HPV strains 1, 8
• Screening must continue regardless of vaccination status—HPV vaccines do not eliminate the need for cervical cancer screening per established guidelines 8, 3
• Single-dose schedules remain controversial and are not currently recommended in the United States, despite some evidence of antibody response 8, 3
• The vaccine is highly immunogenic, with highest antibody responses in girls aged 9-15 years, supporting early vaccination 1