Repeat Testing Interval for Normal PAP with Positive HPV
For a patient with a normal PAP smear but positive high-risk HPV test, repeat HPV testing with or without concurrent PAP should be performed in 1 year. 1
Management Algorithm
Initial Assessment
- If HPV genotyping shows HPV 16 or 18: Proceed directly to colposcopy regardless of normal cytology, as these genotypes carry the highest risk (17% and 14% respectively for CIN 3+) 1, 2
- If HPV type is non-16/18 high-risk: Return in 1 year for repeat testing 1
One-Year Follow-Up Testing
The preferred approach is HPV testing with or without concurrent PAP (cotesting), rather than cytology alone, as HPV testing is less likely to miss disease 1
At the 1-year follow-up visit:
- If both tests are negative: Return to routine 3-year screening intervals 1, 3
- If HPV remains positive OR cytology is abnormal: Refer for colposcopy 1
- If HPV positive but cytology normal: Repeat testing in another year or consider colposcopy 1, 3
Two Consecutive Positive HPV Tests
- Colposcopy is always recommended for two consecutive HPV-positive tests, regardless of cytology results 1
Key Evidence Supporting 1-Year Interval
The 2021 CDC STI Treatment Guidelines and 2019 ASCCP Risk-Based Management Consensus Guidelines both specify that women with normal cytology but positive high-risk HPV should be retested at 1 year 1. This represents a change from older 2012 guidelines that recommended immediate colposcopy for all HPV-positive results 1.
The rationale for 1-year surveillance rather than immediate colposcopy includes:
- Risk stratification shows that a single HPV-positive result with normal cytology in women with recent negative screening history (within 5 years) carries lower immediate risk for CIN 3+ 1
- Many HPV infections clear spontaneously within 12-24 months, particularly in younger women 1
- Persistent HPV positivity at 1 year significantly elevates risk and warrants colposcopy 1
Critical Pitfalls to Avoid
Do not extend the screening interval beyond 1 year for initial follow-up of HPV-positive, cytology-negative results 3. The first follow-up must occur at 1 year to ensure appropriate surveillance.
Do not use cytology alone for follow-up testing. HPV testing or cotesting is preferred because it has higher sensitivity (88-90%) for detecting high-grade lesions compared to cytology alone (76.2%) 2, 4
Do not assume this represents routine screening. A positive HPV test, even with normal cytology, places the patient in a surveillance protocol rather than routine screening 1. She cannot return to 3-year intervals until demonstrating negative results.
For women over age 30: HPV positivity is more concerning and less likely to represent transient infection, with higher risk of underlying significant disease 2. The 1-year follow-up is particularly important in this age group.
Special Consideration for Previous Screening History
If the patient had a negative HPV test or cotest within the previous 5 years before this current positive result, the risk is lower and 1-year follow-up is appropriate 1. However, if there is no recent negative screening history, some guidelines suggest colposcopy may be considered, though 1-year follow-up remains acceptable 1.