Diagnosis, treatment, and follow-up of human papillomavirus (HPV)-related lesions in human immunodeficiency virus (HIV)-infected patients should be performed in consultation with a clinician experienced in the management of HPV and HIV.
Prevention of HPV
HPV Vaccine
Clinicians should offer the HPV vaccine to HIV-infected women between the ages of 9 and 26 years.
Clinicians should continue to obtain cervical Pap tests on the recommended schedule in HIV-infected women who have been vaccinated with HPV vaccine (see "Screening for HPV" section below). Vaginal and vulvar visual inspection should be continued at regularly scheduled pelvic examinations.
HPV typing prior to administering the vaccine is not recommended.
There currently are no recommendations to vaccinate males against HPV.
Other Strategies to Prevent HPV Infection
Clinicians should counsel HIV-infected patients on practices that may reduce the risk of acquiring HPV infection, including safe sexual practices and reduction in number of sexual partners.
Screening for HPV
Visual Inspection
Clinicians should examine the anogenital area, including the vulva and vagina in women, to assess for visible HPV lesions at baseline and as part of the annual comprehensive physical examination.
Cervical Cytology
Clinicians should obtain cervical Pap tests in HIV-infected women at baseline, 6 months after baseline, and then annually as long as results are normal. Colposcopy should be performed for women with abnormal Pap tests (atypical squamous cells of uncertain significance [ASC-US], atypical squamous cells: cannot exclude high grade squamous intraepithelial lesion ASC-H, low-grade squamous intraepithelial lesion [LSIL], or high-grade squamous intraepithelial lesion [HSIL], or the World Health Organization (WHO) or cervical intraepithelial neoplasia [CIN] equivalent); treatment would then vary according to individual colposcopy results. After treatment, Pap tests should be repeated every 3 to 6 months until there have been two successive normal Pap tests.
For Women Who Have Undergone Hysterectomy
Clinicians should obtain at least an annual cervical Pap test in HIV-infected women who have undergone a hysterectomy when:
- The hysterectomy was performed because of high-grade dysplasia, HPV-related anogenital dysplasia of the cervix, or carcinoma
- A supracervical hysterectomy (uterus removed and cervix left in place) was performed
- The reason for the hysterectomy cannot be determined by patient self-report or other means
- Any cervical tissue remains
Annual Pap tests are not recommended for HIV-infected women who have undergone a total hysterectomy for reasons not related to cervical abnormalities.
Anal Cytology
Clinicians should perform anal Pap tests at baseline and annually in the following populations:
- Men who have sex with men
- Any patient with a history of anogenital condylomas
- Women with abnormal cervical/vulvar histology
HPV Deoxyribonucleic Acid (DNA) Testing
HPV DNA testing in HIV-infected patients is not recommended at this time.
Presentation and Diagnosis
Clinicians should include HPV in the differential diagnosis of anogenital symptoms, such as itching, bleeding, pain, or spotting after sexual intercourse.
Patients with abnormal anogenital physical findings, such as warts, hypopigmented or hyperpigmented plaques/lesions, lesions that bleed, or any other lesions of uncertain etiology, should be referred for high-resolution anoscopy, a cervical Pap test (for women), and/or examination with biopsy of abnormal findings.
Treatment
Clinicians should use the same therapeutic modalities to treat HPV in HIV-infected patients as those used in non-HIV-infected patients (see Table 1 below). The following factors should be considered when choosing treatment:
- Patient preference
- Clinician experience and available resources
- Size of wart(s) and number of warts
- Anatomic site of wart(s)
- Adverse effects of treatment
Clinicians should switch treatment modalities if warts have not improved substantially within 3 months of therapy. For condyloma that have not responded to treatment, clinicians should obtain biopsy to exclude dysplasia or cancer.
Clinicians should not use podophyllotoxin or interferon in pregnant women.
Clinicians should refer patients with lesions that are resistant to simple therapies, lesions that change in appearance, and lesions with ulceration, irregular shape, or variegated coloration to clinicians experienced in the management of HPV and HIV.
Primary care clinicians should refer HIV-infected patients with cervical, vulvar, or anal cancer to an oncologist for treatment (see the New York State Department of Health (NYSDOH) guidelines "Neoplastic Complications" and "Anogenital Neoplasia" for further discussion regarding treatment of cancer).
Table 1. Available Treatment Options for Condyloma
| Patient-Applied Treatments |
Provider-Applied Treatments |
- Podophyllotoxin*
- Imiquimod**
- Cidofovir gel
|
- Cryotherapy
- Podophyllin resin*
- Trichloroacetic acid (TCA)
- Bichloroacetic acid (BCA) 80%-90%
- Interferon alfa-2b*
- Electrodesiccation
- Surgical excision
- Laser (carbon dioxide, pulsed-dye)
- Loop electrosurgical excision procedure (LEEP)
- Infrared coagulation
|
*Should not be used in pregnant women. TCA or BCA can be used to treat small external warts during pregnancy but may not be as effective.
** May decrease likelihood of recurrences.
Management of Sex Partners
Clinicians should consider both the HIV exposure and the sexually transmitted infection (STI) exposure to partners when HIV-infected patients present with a new STI. Clinicians should also assess for the presence of other STIs.
Management of HIV Exposure
When HIV-infected patients present with a new STI, clinicians should encourage their partner(s) to undergo HIV testing at baseline, 1, 3, and 6 months. In New York State, if the test result is positive, a Western blot assay must be performed to confirm diagnosis of HIV infection.
Clinicians should be vigilant for any post-exposure acute febrile illness accompanied by rash, lymphadenopathy, myalgias, and/or sore throat. If the partner presents with signs or symptoms of acute HIV seroconversion, a quantitative ribonucleic acid polymerase chain reaction (RNA PCR) should be obtained, and consultation with an HIV Specialist should be sought. Positive RNA tests should be confirmed with HIV antibody testing performed within 6 weeks of the RNA test.
Clinicians should offer assistance with partner notification if needed.
Management of HPV Exposure
For sex partners of patients with genital warts, clinicians should:
- Examine sex partners for the presence of genital warts and other STIs
- Counsel female sex partners about the importance of cervical cytologic screening
