What are the management and screening recommendations for a patient who is HPV positive?

Management of HPV-Positive Patients

For patients testing positive for HPV, management depends critically on HPV genotype (specifically HPV 16/18 vs. other high-risk types) and concurrent cytology results, with immediate colposcopy required for HPV 16/18 regardless of cytology, while other high-risk HPV types with normal cytology warrant repeat testing at 12 months. 1, 2

Initial Risk Stratification by HPV Type

HPV 16 or 18 Positive (Highest Risk)

• Proceed immediately to colposcopy regardless of cytology results due to the 17-21% 10-year cumulative risk of CIN 3 or worse 2
• HPV-16 accounts for 50-60% of cervical cancer cases, with HPV-18 responsible for 10-12% 3
• Endocervical sampling should be performed at colposcopy, particularly for HPV-18 due to its association with adenocarcinoma 1, 2
• If HPV 16 is detected with high-grade squamous intraepithelial lesion (HSIL) cytology, expedited treatment should be considered 1

Other High-Risk HPV Types with Normal Cytology (Lower Risk)

• Schedule repeat co-testing (HPV and cytology) at 12 months rather than immediate colposcopy 1, 2
• This conservative approach is justified because approximately 60% of high-risk HPV infections clear spontaneously within one year 1
• The risk of CIN 3+ is only 1.5-3%, which falls below the threshold for immediate colposcopy 1
• At 12-month follow-up, proceed to colposcopy if HPV remains positive or cytology becomes abnormal 1

Management Algorithm Based on Cytology Results

Normal Cytology with HPV Positive (Non-16/18)

• Repeat HPV and cytology testing at 12 months 1
• If both tests are negative at 12 months, return to routine age-based screening 1
• If HPV remains positive at 12 months (regardless of cytology), proceed to colposcopy with endocervical sampling 1
• If cytology shows any abnormality at 12 months (regardless of HPV status), proceed to colposcopy 1

Abnormal Cytology Results

• Low-grade squamous intraepithelial lesion (LSIL) or worse cytology warrants colposcopy in adults over 30 years 3
• HPV-positive atypical squamous cells of undetermined significance (ASC-US) is an indication for colposcopy 3
• Atypical glandular cells (AGC) combined with HPV 16/18/45 indicates a 12% absolute risk of adenocarcinoma/AIS and requires immediate colposcopy 4

Colposcopy and Biopsy Protocol

Colposcopy Procedure

• Colposcopy is the primary diagnostic approach following a positive cervical cancer screen 3
• Apply 3-5% acetic acid solution and obtain colposcopically-directed biopsies from all visible acetowhite lesions 2
• Colposcopy sensitivity ranges from 60.6% for a single biopsy to 95.6% for three biopsies 3
• Endocervical sampling is recommended when endocervical canal extension is suspected 3

Timing of Diagnostic Testing

• Diagnostic colposcopy should occur within 60-90 days of a positive screening result 3
• Evidence suggests non-significant increase in disease risk as early as 90 days after positive screen 3

Management Based on Biopsy Results

CIN 1 or Less

• Repeat HPV testing with or without Pap test in 1 year 3, 1
• If negative at 6 and 12 months, return to normal screening schedule 3
• Most lesions will regress to normal spontaneously 3

CIN 2 or CIN 3 (High-Grade Lesions)

• Treatment is indicated with excisional procedures (LEEP or cold-knife conization) or ablation 3, 1, 2
• CIN 2 may be followed without treatment in select circumstances (young women desiring fertility who are reliable with follow-up) 3
• Total hysterectomy may be considered for CIN 3 if indicated for other pathologic conditions, but initial LEEP or CKC is recommended first to confirm diagnosis 3

Post-Treatment Surveillance

Long-Term Follow-Up Requirements

• Surveillance must continue for at least 25 years after treatment for high-grade precancer, even extending past age 65 3, 1, 2
• Initial post-treatment testing includes HPV test or co-test at 6,18, and 30 months 1, 2
• Long-term surveillance includes testing at 3-year intervals if using HPV testing or co-testing 1
• Annual testing is required if using cytology alone 1

Patient Counseling and Education

Essential Communication Points

• Frame HPV positivity in a neutral, non-stigmatizing context emphasizing its common, asymptomatic, and transient nature 3
• HPV infections are extremely common in sexually active women and the vast majority spontaneously resolve 3
• Persistent infection with high-risk types is required for cervical cancer development, but very few HPV-positive women ultimately develop cancer 3
• HPV tests might become positive many years after initial exposure due to reactivation of latent infections 3

Addressing Psychosocial Concerns

• A positive HPV test can cause short-term anxiety, stress, fear, and confusion 3
• Providers should be prepared to discuss that it is often not possible to know the origin of an HPV infection 3
• Having an HPV infection should not raise concerns about a male partner's health 3
• Providers play a crucial role in moderating the psychosocial impact of abnormal results 3

Critical Pitfalls to Avoid

Testing Errors

• Do not perform HPV testing for low-risk HPV types (e.g., types 6 and 11) 1
• Do not use HPV testing to decide whether to vaccinate against HPV 1
• Do not perform HPV testing in persons aged <25 years as part of routine screening 1
• Do not test oral or anal specimens with cervical HPV tests 1

Management Errors

• Do not delay colposcopy for HPV 16/18 positive patients based on negative cytology alone 2
• Do not perform immediate colposcopy for women with negative cytology but positive non-16/18 high-risk HPV 1
• Do not use additional HPV genotyping for further triage in women already confirmed negative for HPV 16/18 1
• Do not perform treatment based on HPV result alone without histologic confirmation of disease 1

Screening Discontinuation Errors

• Do not discontinue screening before age 65 unless adequate prior negative screening is documented 3
• After treatment for CIN 2/3 or adenocarcinoma in situ, routine screening must continue for at least 20 years, even if this extends past age 65 3

Special Considerations

Cofactors Increasing Risk

• Screen for tobacco use and perform cessation counseling, as smoking contributes to CIN progression 3
• Other cofactors that increase risk among HPV-positive women include older age, long-term oral contraceptive use (≥5 years), high parity (≥5 full-term pregnancies), and HIV infection 3

Follow-Up Testing Preferences

• HPV testing or co-testing is preferred over cytology alone for follow-up after an abnormal result, as negative HPV testing is less likely to miss disease than normal cytology alone 1