Cervical HPV Infection

Cervical HPV infection is infection of the cervical epithelium with human papillomavirus. High-risk types (16, 18, 31, 33, 45, 52, 58) cause cervical precancer and cancer; low-risk types (6 and 11) cause warts.

• Most infections clear within 1 to 2 years.
• Persistent high-risk infection leads to cervical intraepithelial neoplasia and cancer over 10 to 20 years, faster in HIV infection.
• No antiviral drug clears HPV; management is by screening and treatment of precancer.

Usually no symptoms.

• Detected on HPV testing; the cervix often looks normal, and VIA may be negative or show acetowhite lesions.
• Differential diagnosis: cervicitis, cervical intraepithelial neoplasia, cervical cancer, cervical polyp, genital warts, cervical ectropion.
• Complications: cervical intraepithelial neoplasia, cervical cancer, vulval, vaginal and anal cancer, genital warts and recurrent respiratory papillomatosis in infants.

Diagnosis is by HPV testing, with visual inspection, colposcopy and biopsy for positive tests.

• HPV DNA test (high-risk types) on a cervical or self-collected vaginal sample.
• VIA or VILI, cervical cytology, colposcopy and biopsy for positive tests.
• HIV and syphilis tests, and tests for other sexually transmitted infections.
• Histology to grade cervical intraepithelial neoplasia (grades 1 to 3).

There is no antiviral treatment; screen, vaccinate, and treat precancer.

• Supportive: counsel that infection is common and usually clears; stop smoking; use condoms; encourage regular screening; inform about HPV vaccination.
• Pharmacological: no antiviral drug. Give HPV vaccine to unvaccinated eligible girls and women, 0.5 mL IM into the deltoid, with the number of doses decided by age and immune status (a single dose in healthy girls aged 9 to 14 years; 3 doses at 0, 1 to 2 and 6 months in HIV infection or immunosuppression). Optimise antiretroviral treatment in HIV infection.
• Procedures: HPV positive and VIA negative: repeat HPV test at 12 months. HPV positive with a lesion that covers less than 75 percent of the cervix and does not extend into the canal or vagina: cryotherapy (3 minutes freeze, 5 minutes thaw, 3 minutes freeze). Larger lesions or extension into the canal: loop electrosurgical excision (LEEP) under 2 percent lignocaine with adrenaline (maximum 7 mg/kg, absolute maximum 500 mg). Invasive cancer: refer for staging and treatment.
• Special groups: in pregnancy defer treatment of cervical intraepithelial neoplasia until 6 weeks after delivery and avoid biopsy unless invasion is suspected. In HIV infection screen more often (every 3 years with an HPV test, or yearly with VIA or cytology) and refer abnormal results early.
• Red flags: post-coital bleeding, irregular or ulcerated cervix, persistent infection after 2 years, high-grade lesion, abnormal discharge with weight loss.
• Follow-up: repeat HPV test at 12 months after a negative result; review at 6 and 12 months after treatment of precancer; screening every 5 years if negative, and every 3 years with an HPV test (or yearly with VIA or cytology) in HIV infection.