Primary HPV Testing Without Pap Smear: Current Recommendations
No, a Pap smear is not necessary after a negative primary HPV test—primary HPV testing alone is now the preferred screening strategy for women aged 25-65 years. 1
Current Screening Guidelines
The American Cancer Society's 2020 guideline represents a fundamental shift in cervical cancer screening:
- Primary HPV testing every 5 years is the preferred strategy for average-risk individuals aged 25-65 years, without requiring concurrent cytology 1
- Cotesting (HPV + Pap) every 5 years or cytology alone every 3 years remain acceptable alternatives only where FDA-approved primary HPV testing is not available 1
- The guideline is explicitly transitional, meaning cotesting and cytology-alone options should be phased out once primary HPV testing becomes universally accessible 1
Why Primary HPV Testing Alone Is Sufficient
The negative predictive value of HPV testing surpasses that of cytology:
- After a negative HPV test, the 10-year cumulative risk of CIN3+ is only 0.31%, which is similar to the 3-year risk after negative cytology (0.30%) 2
- This ultra-low risk supports screening intervals of 5 years or longer after negative HPV testing 3
- HPV testing is 96-100% sensitive for detecting CIN2/3 and cancer, providing superior reassurance compared to cytology alone 4
Sequential negative HPV tests provide exceptional long-term protection:
- The 5-year CIN3+ risk after successive negative HPV tests decreases with each round: 0.073%, 0.042%, and 0.027% 1
- An HPV-negative result nearly matches the performance of a negative cotest, regardless of cytology results 1
Important Caveats and Exceptions
Not all negative results are equivalent—HPV-negative ASC-US requires different management:
- Women with HPV-negative ASC-US results should return for screening in 3 years, not 5 years 1, 5, 6
- The risk after HPV-negative ASC-US is closer to negative cytology alone than to a negative cotest 1
- HPV-negative ASC-US is insufficient for exiting screening at age 65 years 1, 6
Age-specific considerations matter:
- For women under 50 years, screening intervals after negative HPV testing can safely extend to 5 years 3
- For women 50 years and older, the risk is even lower (0.08% 10-year cumulative CIN3+ risk), potentially supporting longer intervals 2
Screening Exit Criteria
Updated 2026 guidance requires HPV testing for screening cessation:
- To exit screening at age 65, women must have negative primary HPV tests (preferred) or negative cotests at ages 60 and 65 years 7
- The last HPV test must be performed at age 65 years or older 7
- If using cytology alone, three consecutive negative Pap tests with the last at age 65 are acceptable but not preferred 7
Common Pitfalls to Avoid
Do not confuse different negative result categories:
- A negative primary HPV test allows 5-year intervals 1, 5
- An HPV-negative ASC-US result requires 3-year follow-up 5, 6
- These are not interchangeable management pathways 5
Do not add unnecessary cytology to negative HPV results:
- Adding cytology to a negative HPV test provides only incremental benefit and is not required in primary HPV screening 1
- The guideline explicitly supports HPV testing as a stand-alone test without concomitant cytology 1
Do not use outdated screening intervals:
- The previous recommendation of annual Pap testing is obsolete 8
- Even cytology-alone screening should occur no more frequently than every 3 years 1
Special Populations Requiring Different Approaches
These recommendations apply only to average-risk individuals and do not apply to: