Management of Positive HPV Testing on Pap Test
Follow the 2019 ASCCP risk-based management guidelines, which stratify management based on individual risk of CIN 3 rather than test results alone, using HPV genotype, cytology results, and screening history to determine whether colposcopy is needed immediately or can be safely deferred for one year. 1
Immediate Colposcopy Required
Proceed directly to colposcopy in the following scenarios:
HPV 16 or 18 positive, regardless of cytology result – Even with normal Pap test, these highest-risk genotypes warrant immediate colposcopy due to their strong association with cervical cancer 1, 2, 3
Two consecutive positive HPV tests – Colposcopy is always recommended regardless of cytology or previous Pap results 1, 2, 3
HPV positive with abnormal cytology – ASC-US, LSIL, ASC-H, or HSIL all require immediate colposcopy 1, 2, 3
History of high-grade lesions – Patients with previous CIN 2/3, histologic or cytologic HSIL, ASC-H, AGC, or AIS may warrant colposcopy even with current low-risk results 1, 2
Deferred Colposcopy (1-Year Follow-Up)
Return in 1 year for repeat HPV testing (with or without Pap) instead of immediate colposcopy if:
- HPV positive (non-16/18 genotype) with normal cytology (NILM) 1, 2, 3
- Minimally abnormal results (ASC-US HPV positive, LSIL HPV positive) AND preceded by negative screening HPV test or cotest within past 5 years 1, 2
Critical caveat: This deferral only applies if the previous negative HPV test or cotest was performed for screening purposes, not during surveillance for a previous abnormality 1
At the 1-year follow-up visit:
- If cytology is abnormal or HPV test remains positive → refer to colposcopy 1, 2, 3
- If HPV test is negative → return to routine screening intervals 2
Primary HPV Screening Considerations
When HPV testing is used as the primary screening method (not cytology):
- Reflex cytology must be performed on all positive HPV results to guide next management steps 1, 3
- Ideally, cytology should be performed by the laboratory from the same specimen to avoid requiring patient return 1, 3
- If infeasible for patient to return for cytology alone, colposcopy can be considered 1
Post-Treatment Surveillance
After treatment for high-grade precancer (CIN 2/3), surveillance must continue for at least 25 years: 1, 2, 3
- Initial testing at 6,18, and 30 months using HPV test or cotest 1, 2, 3
- If cytology alone is used: testing at 6,12,18,24, and 30 months 1
- After completing initial testing: long-term surveillance every 3 years with HPV/cotest or annually with cytology alone 1, 3
Follow-Up Testing Preferences
HPV testing or cotesting is strongly preferred over cytology alone for follow-up after abnormal results because negative HPV testing is less likely to miss disease than normal cytology alone 1, 2
The testing frequency differs based on method:
- When HPV testing/cotesting is recommended at 3-year intervals → cytology alone should be performed annually 1
- When HPV testing/cotesting is recommended annually → cytology alone should be performed at 6-month intervals 1
Common Pitfalls to Avoid
Never dismiss HPV-positive results with normal cytology – Persistent HPV infection is a significant risk factor for cervical cancer, with approximately 63% of adenocarcinomas diagnosed over 5-year periods following an HPV-positive, cytology-negative cotest 2
Do not use HPV testing in patients <25 years as part of routine cervical cancer screening, as HPV infection is common and usually transient in young women 1, 4
Recognize that negative colposcopy does not eliminate HPV – Colposcopy only evaluates morphological changes, not molecular presence of virus; approximately 40% of high-risk HPV infections persist beyond 12 months 2
Understand that patients with persistent HPV over 5 years have approximately 20.4% cumulative risk of CIN3+ and require immediate colposcopy 2
FDA-cleared HPV tests are only approved for cervical specimens – Do not use for oral or anal specimens 1
Do not test for low-risk HPV types (e.g., types 6 and 11) as this is not recommended 1