Recommended Follow-Up for Normal Pap with HPV-Positive (Non-16/18/45) Result
Repeat Pap and HPV cotesting in 1 year is the recommended management for a woman of reproductive age with normal cytology and positive high-risk HPV that is negative for types 16,18, and 45. 1
Management Algorithm
The 1-year follow-up interval is specifically indicated for this clinical scenario:
- Women with normal Pap smears but positive high-risk HPV (excluding types 16,18, and 45) should undergo repeat testing in 1 year with HPV testing with or without concurrent Pap 1
- This recommendation is based on the 2021 CDC STI Treatment Guidelines and 2019 ASCCP Risk-Based Management Consensus Guidelines 1
- The presence of non-16/18 high-risk HPV types with normal cytology carries lower immediate risk for CIN3+ compared to HPV 16/18 positivity 2, 1
What Happens at the 1-Year Follow-Up Visit
Testing options and subsequent management:
- The preferred approach is HPV testing with or without concurrent Pap, rather than cytology alone, as HPV testing provides superior disease detection 1
- If both tests are negative at 1 year, return to routine 3-year screening intervals 1
- If HPV remains positive or cytology becomes abnormal, refer for colposcopy 1
Why Not Immediate Colposcopy
Colposcopy is not indicated in this scenario because:
- HPV types 16 and 18 are the only genotypes that warrant immediate colposcopy despite normal cytology, as they carry the highest risk for CIN3+ 1
- Your patient tested negative for HPV 16,18, and 45, placing her in a lower-risk category 1
- Many HPV infections clear spontaneously within 12-24 months, particularly in younger women of reproductive age 1
Why Not 3-Year or 5-Year Intervals
Longer intervals are inappropriate for this result:
- Five-year intervals are only appropriate for women aged 30 years and older with completely negative cotesting (both Pap and HPV negative) 3, 4
- Three-year intervals apply to women with resolved HPV infections (previously positive, now negative) or those with negative cotesting who are under age 30 3
- A single HPV-positive result with normal cytology requires closer surveillance than completely negative results 1
Risk Stratification Context
Understanding the risk level:
- Persistent HPV positivity at 1 year significantly elevates risk and warrants colposcopy 1
- Type-specific persistent infections carry a 10-year cumulative CIN3+ risk of 20.4%, while new infections carry only 3.4% risk 5
- About three-quarters of women with HPV infection and normal cytology clear their infections within approximately 3 years 5
Common Pitfalls to Avoid
Key management errors to prevent:
- Do not extend the screening interval beyond 1 year for HPV-positive women with normal cytology, even though immediate risk is relatively low 1
- Do not perform HPV 16/18 genotyping for women who already have normal cytology with non-16/18 HPV, as it does not alter management 2
- Do not confuse this scenario with HPV-negative/ASC-US results, which require 3-year follow-up 4