Human Papillomavirus
Infection Treatment
Genital
Warts
More than 30
types of HPV can infect the genital tract. Most HPV infections are
asymptomatic, unrecognized, or subclinical. Visible genital warts
usually are caused by HPV types 6 or 11. Other HPV types in the
anogenital region (e.g., types 16, 18, 31, 33, and 35) have been
strongly associated with cervical neoplasia. Diagnosis of genital
warts can be confirmed by biopsy, although biopsy is needed only
under certain circumstances (e.g., if the diagnosis is uncertain;
the lesions do not respond to standard therapy; the disease worsens
during therapy; the patient is immunocompromised; or warts are pigmented,
indurated, fixed, and ulcerated). No data support the use of type-specific
HPV nucleic acid tests in the routine diagnosis or management of
visible genital warts.
In addition
to the external genitalia (i.e., the penis, vulva, scrotum, perineum,
and perianal skin), genital warts can occur on the uterine cervix
and in the vagina, urethra, anus, and mouth; these warts are sometimes
symptomatic. Intra-anal warts are seen predominantly in patients
who have had receptive anal intercourse; these warts are distinct
from perianal warts, which can occur in men and women who do not
have a history of anal sex. In addition to the genital area, HPV
types 6 and 11 have been associated with conjunctival, nasal, oral,
and laryngeal warts. HPV types 6 and 11 rarely are associated with
invasive squamous cell carcinoma of the external genitalia. Depending
on the size and anatomic location, genital warts can be painful,
friable, and pruritic, although they are commonly asymptomatic.
HPV types 16,
18, 31, 33, and 35 are found occasionally in visible genital warts
and have been associated with external genital (i.e., vulvar, penile,
and anal) squamous intraepithelial neoplasia (i.e., squamous cell
carcinoma in situ, bowenoid papulosis, Erythroplasia of Queyrat,
or Bowen's disease of the genitalia). These HPV types also have
been associated with vaginal, anal, and cervical intraepithelial
dysplasia and squamous cell carcinoma. Patients who have visible
genital warts can be infected simultaneously with multiple HPV types.
Treatment
The primary
goal of treating visible genital warts is the removal of symptomatic
warts. In most patients, treatment can induce wart-free periods.
If left untreated, visible genital warts may resolve on their own,
remain unchanged, or increase in size or number. Determining whether
treatment of genital warts will reduce transmission is difficult,
because no laboratory marker of infectivity has been established
and because clinical studies evaluating the persistence of HPV DNA
in genital tissue after treatment have shown variable results. Existing
data indicate that currently available therapies for genital warts
may reduce, but probably do not eradicate, infectivity. Whether
the reduction in viral DNA that results from current treatment regimens
impacts future transmission remains unclear. No evidence indicates
that either the presence of genital warts or their treatment is
associated with the development of cervical cancer.
Regimens
Treatment of
genital warts should be guided by the preference of the patient,
the available resources, and the experience of the health-care provider.
No definitive evidence suggests that any of the available treatments
is superior to the others, and no single treatment is ideal for
all patients or all warts. The use of locally developed and monitored
treatment algorithms has been associated with improved clinical
outcomes and should be encouraged. Because of uncertainty regarding
the effect of treatment on future transmission and the possibility
for spontaneous resolution, an acceptable alternative for some patients
is to forego treatment and await spontaneous resolution.
Most patients
have <10 genital warts, with a total wart area of 0.5--1.0
cm2. These warts respond to most treatment modalities.
Factors that may influence selection of treatment include wart size,
wart number, anatomic site of wart, wart morphology, patient preference,
cost of treatment, convenience, adverse effects, and provider experience.
Many patients require a course of therapy rather than a single treatment.
In general, warts located on moist surfaces and/or in intertriginous
areas respond better to topical treatment than do warts on drier
surfaces.
The treatment
modality should be changed if a patient has not improved substantially
after three provider-administered treatments or if warts have not
completely cleared after six treatments. The risk-benefit ratio
of treatment should be evaluated throughout the course of therapy
to avoid overtreatment. Both patient-applied therapies and provider-administered
therapies are available. Providers should be knowledgeable about,
and have available to them, at least one patient-applied and one
provider-administered treatment.
Complications
rarely occur if treatments for warts are employed properly. Patients
should be warned that persistent hypopigmentation or hyperpigmentation
are common with ablative modalities. Depressed or hypertrophic scars
are uncommon but can occur, especially if the patient has had insufficient
time to heal between treatments. Rarely, treatment can result in
disabling chronic pain syndromes (e.g., vulvodynia or hyperesthesia
of the treatment site).
Recommended
Regimens for External Genital Warts
Patient-Applied:
Podofilox
0.5% solution or gel. Patients should apply podofilox
solution with a cotton swab, or podofilox gel with a finger,
to visible genital warts twice a day for 3 days, followed by
4 days of no therapy. This cycle may be repeated, as necessary,
for up to four cycles. The total wart area treated should not
exceed 10 cm2, and the total volume of podofilox
should be limited to 0.5 mL per day. If possible, the health-care
provider should apply the initial treatment to demonstrate the
proper application technique and identify which warts should
be treated. The safety of podofilox during pregnancy has not
been established.
OR
Imiquimod 5% cream. Patients should apply imiquimod
cream once daily at bedtime, three times a week for up to 16
weeks. The treatment area should be washed with soap and water
6--10 hours after the application. The safety of imiquimod during
pregnancy has not been established.
Provider-Administered:
Cryotherapy
with liquid nitrogen or cryoprobe. Repeat applications
every 1--2 weeks.
OR
Podophyllin resin 10%--25% in a compound tincture of
benzoin. A small amount should be applied to each wart and allowed
to air dry. The treatment can be repeated weekly, if necessary.
To avoid the possibility of complications associated with systemic
absorption and toxicity, some specialists recommend that application
be limited to <0.5 mL of podophyllin or an area of
<10 cm2 of warts per session. Some specialists
suggest that the preparation should be thoroughly washed off
1--4 hours after application to reduce local irritation. The
safety of podophyllin during pregnancy has not been established.
OR
Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%--90%.
A small amount should be applied only to warts and allowed to
dry, at which time a white "frosting" develops. If an excess
amount of acid is applied, the treated area should be powdered
with talc, sodium bicarbonate (i.e., baking soda), or liquid
soap preparations to remove unreacted acid. This treatment can
be repeated weekly, if necessary.
OR
Surgical removal either by tangential scissor excision,
tangential shave excision, curettage, or electrosurgery.
Alternative
Regimens
Intralesional
interferon
OR
Laser surgery.
For patient-applied
treatments, patients must be able to identify and reach warts to
be treated. Podofilox 0.5% solution or gel, an antimitotic drug
that destroys warts, is relatively inexpensive, easy to use, safe,
and self-applied by patients. Most patients experience mild/moderate
pain or local irritation after treatment. Imiquimod is a topically
active immune enhancer that stimulates production of interferon
and other cytokines. Local inflammatory reactions are common with
the use of imiquimod; these reactions usually are mild to moderate.
Traditionally, follow-up visits are not required for patients using
self-administered therapy. However, follow-up may be useful several
weeks into therapy to determine appropriateness of medication use
and response to treatment.
Cryotherapy
destroys warts by thermal-induced cytolysis. Health-care providers
must be trained on the proper use of this therapy, because over-
and under-treatment may result in poor efficacy or increased likelihood
of complications. Pain after application of the liquid nitrogen,
followed by necrosis and sometimes blistering, is common. Local
anesthesia (topical or injected) may facilitate therapy if warts
are present in many areas or if the area of warts is large.
Podophyllin
resin, which contains several compounds including antimitotic podophyllin
lignans, is another treatment option. The resin is most frequently
compounded at 10%--25% in a tincture of benzoin. However, podophyllin
resin preparations differ in the concentration of active components
and contaminants. The shelf life and stability of podophyllin preparations
are unknown. A thin layer of podophyllin resin must be applied to
the warts and allowed to air dry before the treated area comes into
contact with clothing; over-application or failure to air dry can
result in local irritation caused by spread of the compound to adjacent
areas.
Both TCA and
BCA are caustic agents that destroy warts by chemical coagulation
of the proteins. Although these preparations are widely used, they
have not been investigated thoroughly. TCA solutions have a low
viscosity comparable with that of water and can spread rapidly if
applied excessively; thus, they can damage adjacent tissues. Both
TCA and BCA should be applied sparingly and allowed to dry before
the patient sits or stands. If pain is intense, the acid can be
neutralized with soap or sodium bicarbonate.
Surgical therapy
is a treatment option that has the advantage of usually eliminating
warts at a single visit. However, such therapy requires substantial
clinical training, additional equipment, and a longer office visit.
Once local anesthesia is applied, the visible genital warts can
be physically destroyed by electrocautery, in which case no additional
hemostasis is required. Care must be taken to control the depth
of electrocautery to prevent scarring. Alternatively, the warts
can be removed either by tangential excision with a pair of fine
scissors or a scalpel or by curettage. Because most warts are exophytic,
this can be accomplished with a resulting wound that only extends
into the upper dermis. Hemostasis can be achieved with an electrosurgical
unit or a chemical styptic (e.g., an aluminum chloride solution).
Suturing is neither required nor indicated in most cases when surgical
removal is done properly. Surgical therapy is most beneficial for
patients who have a large number or area of genital warts. Carbon
dioxide laser and surgery may be useful in the management of extensive
warts or intraurethral warts, particularly for those patients who
have not responded to other treatments.
Interferons,
either natural or recombinant, used for the treatment of genital
warts have been administered systemically (i.e., subcutaneously
at a distant site or IM) and intralesionally (i.e., injected into
the warts). Systemic interferon is not effective. The efficacy and
recurrence rates of intralesional interferon are comparable to other
treatment modalities. Interferon is likely effective because of
its anti-viral and/or immunostimulating effects. However, interferon
therapy is not recommended for routine use because of inconvenient
routes of administration, frequent office visits, and the association
between its use and a high frequency of systemic adverse effects.
Because of the
shortcomings of all available treatments, some clinics employ combination
therapy (i.e., the simultaneous use of two or more modalities on
the same wart at the same time). However, some specialists believe
that combining modalities may increase complications without improving
efficacy.
Cervical
Warts
For women who
have exophytic cervical warts, high-grade squamous intraepithelial
lesions (SIL) must be excluded before treatment is initiated. Management
of exophytic cervical warts should include consultation with a specialist.
Recommended
Regimens for Vaginal Warts
Cryotherapy
with liquid nitrogen. The use of a cryoprobe in the
vagina is not recommended because of the risk for vaginal perforation
and fistula formation.
OR
TCA or BCA 80%--90% applied to warts. A small amount
should be applied only to warts and allowed to dry, at which
time a white "frosting" develops. If an excess amount of acid
is applied, the treated area should be powdered with talc, sodium
bicarbonate (i.e., baking soda), or liquid soap preparations
to remove unreacted acid. This treatment can be repeated weekly,
if necessary.
Recommended
Regimens for Urethral Meatus Warts
Cryotherapy
with liquid nitrogen
OR
Podophyllin 10%--25% in compound tincture of benzoin.
The treatment area must be dry before contact with normal mucosa.
This treatment can be repeated weekly, if necessary. The safety
of podophyllin during pregnancy has not been established.
NOTE:
Although data evaluating the use of podofilox and imiquimod
for the treatment of distal meatal warts are limited, some specialists
recommend their use in certain patients.
Recommended
Regimens for Anal Warts
Cryotherapy
with liquid nitrogen
OR
TCA or BCA 80%--90% applied to warts. A small amount
should be applied only to warts and allowed to dry, at which
time a white "frosting" develops. If an excess amount of acid
is applied, the treated area should be powdered with talc, sodium
bicarbonate (i.e., baking soda), or liquid soap preparations
to remove unreacted acid. This treatment can be repeated weekly,
if necessary.
OR
Surgical removal.
NOTE:
Warts on the rectal mucosa should be managed in consultation
with a specialist.
Recommended
Regimens for Oral Warts
Cryotherapy
with liquid nitrogen
OR
Surgical removal.
Education and
counseling are important aspects of managing patients with genital
warts. Patients can be educated through patient education materials,
including pamphlets, hotlines, and web sites (http://www.ashastd.org/).
Attempts should be made to cover the following key messages.
- Genital HPV
infection is a viral infection that is common among sexually active
adults.
- Infection
is almost always sexually transmitted, but the incubation period
is variable and it is often difficult to determine the source
of infection. Within ongoing relationships, sex partners usually
are infected by the time of the patient's diagnosis, although
they may have no symptoms or signs of infection.
- The natural
history of genital warts is generally benign; the types of HPV
that usually cause external genital warts are not associated with
cancer. Recurrence of genital warts within the first several months
after treatment is common and usually indicates recurrence rather
than reinfection.
- The likelihood
of transmission to future partners and the duration of infectivity
after treatment are unknown. The use of latex condoms has been
associated with a lower rate of cervical cancer, an HPV-associated
disease.
- Because genital
HPV is common among persons who have been sexually active and
because the duration of infectivity is unknown, the value of disclosing
a past diagnosis of genital HPV infection to future partners is
unclear. Candid discussions about other STDs should be encouraged
and attempted whenever possible.
Follow-Up
After visible
genital warts have cleared, a follow-up evaluation is not mandatory
but may be helpful. Patients should be cautioned to watch for recurrences,
which occur most frequently during the first 3 months. Because the
sensitivity and specificity of self-diagnosis of genital warts are
unknown, patients concerned about recurrences should be offered
a follow-up evaluation 3 months after treatment. Earlier follow-up
visits also may be useful for some patients to document the absence
of warts, to monitor for or treat complications of therapy, and
to provide an additional opportunity for patient education and counseling.
Women should be counseled to undergo regular Pap screening as recommended
for women without genital warts. The presence of genital warts is
not an indication for a change in the frequency of Pap tests or
for cervical colposcopy.
Management
of Sex Partners
Examination
of sex partners is not necessary for the management of genital warts
because no data indicate that reinfection plays a role in recurrences.
Additionally, providing treatment solely for the purpose of preventing
future transmission cannot be recommended because the value of treatment
in reducing infectivity is not known. However, because self- or
partner-examination has not been evaluated as a diagnostic method
for genital warts, sex partners of patients who have genital warts
may benefit from examination to assess the presence of genital warts
and other STDs. The counseling of sex partners provides an opportunity
for these partners to a) learn about implications of having a partner
who has genital warts and about their potential for future disease
transmission and b) receive STD and Pap screening. Female sex partners
of patients who have genital warts should be reminded that cytologic
screening for cervical cancer is recommended for all sexually active
women.
Special
Considerations
Pregnancy
Imiquimod, podophyllin,
and podofilox should not be used during pregnancy. Because genital
warts can proliferate and become friable during pregnancy, many
specialists advocate their removal during pregnancy. HPV types 6
and 11 can cause respiratory papillomatosis in infants and children.
The route of transmission (i.e., transplacental, perinatal, or postnatal)
is not completely understood. The preventive value of cesarean section
is unknown; thus, cesarean delivery should not be performed solely
to prevent transmission of HPV infection to the newborn. Cesarean
delivery may be indicated for women with genital warts if the pelvic
outlet is obstructed or if vaginal delivery would result in excessive
bleeding.
Immunodeficient
Patients
Persons who
are immunosuppressed because of HIV or other reasons may not respond
as well as immunocompetent persons to therapy for genital warts,
and they may have more frequent recurrences after treatment. Squamous
cell carcinomas arising in or resembling genital warts may occur
more frequently among immunosuppressed persons, thus requiring biopsy
for confirmation of diagnosis. Because of the increased incidence
of anal cancer in HIV-infected homosexual men, screening for anal
SIL by cytology in this population is advocated by some specialists.
However, until more data about the natural history of anal SIL and
treatment efficacy are available, such a screening approach is not
recommended.
Squamous
Cell Carcinoma in Situ
Patients in
whom squamous cell carcinoma in situ of the genitalia is diagnosed
should be referred to a specialist for treatment. Ablative modalities
usually are effective, but careful follow-up is important. The risk
for these lesions leading to invasive squamous cell carcinoma of
the external genitalia in immunocompetent patients is unknown but
is probably low. Female partners of male patients who have squamous
cell carcinoma in situ are at high risk for cervical abnormalities.
Subclinical
Genital HPV Infection (Without Exophytic Warts)
Subclinical
genital HPV infection is a term often used to refer to manifestations
of infection in the absence of genital warts, including situations
where infection is detected on the cervix by Pap test, colposcopy,
or biopsy; on the penis, vulva, or other genital skin by the appearance
of white areas after application of acetic acid; or on any genital
skin by a positive test for HPV.
Subclinical
genital HPV infection occurs more frequently than visible genital
warts among both men and women. Subclinical infection of the cervix
is most commonly diagnosed by Pap screening with the detection of
squamous intraepithelial lesions. The application of 3%--5% acetic
acid usually turns HPV-infected genital mucosal tissue a whitish
color. However, acetic acid application is not a specific test for
HPV infection, and the specificity and sensitivity of this procedure
for screening have not been defined. Thus, the routine use of this
procedure for screening to detect subclinical infection is not recommended.
However, some experienced clinicians find this test useful for identification
of flat genital warts.
A definitive
diagnosis of HPV infection is based on detection of viral nucleic
acid (DNA or RNA) or capsid protein. Pap-test diagnosis of HPV does
not always correlate with detection of HPV DNA in cervical cells.
Cell changes attributed to HPV in the cervix are similar to those
of SIL and often regress spontaneously without treatment. Tests
that detect several types of HPV DNA in cells scraped from the cervix
are available and may be useful in the triage of women with atypical
squamous cells of undetermined significance (ASCUS) but not other
types of cytologic abnormalities. Screening for subclinical genital
HPV infection using DNA or RNA tests is not recommended.
Treatment
In the absence
of coexistent SIL, treatment is not recommended for subclinical
genital HPV infection diagnosed by colposcopy, biopsy, acetic acid
application, or the detection of HPV by laboratory tests. The diagnosis
of subclinical genital HPV infection is often not definitive, and
no therapy has been identified that eradicates infection. In the
presence of coexistent SIL, management should be based on histopathologic
findings.
Management
of Sex Partners
Examination
of sex partners is unnecessary. Most sex partners of infected patients
probably are already infected subclinically with HPV. No screening
tests for subclinical infection are available. Likewise, whether
patients who have subclinical HPV infection are as infectious as
patients who have exophytic warts is unknown.
Cervical
Cancer Screening for Women Who Attend STD Clinics or Have a History
of STDs
Women with a
history of STD may be at increased risk for cervical cancer, and
women attending STD clinics may have other risk factors that place
them at even greater risk. Prevalence studies have determined that
precursor lesions for cervical cancer occur about five times more
frequently among women attending STD clinics than among women attending
family planning clinics (92). The cervical Pap test is
an effective, low-cost screening test for preventing invasive cervical
cancer. Recommendations regarding Pap testing intervals vary in
the United States (93,94,10). However, if a woman has three
consecutive negative annual Pap tests, future screening tests may
be performed less frequently.
Recommendations
At the time
of a pelvic examination for STD screening, the health-care provider
should inquire about the result of the patient's last Pap test and
discuss the following information with the patient:
- the purpose
and importance of a Pap test;
- whether a
Pap test was obtained during the clinic visit;
- the need
for a regular Pap test; and
- if a Pap
test was not obtained during this examination, the names of local
providers or referral clinics that can obtain Pap tests and adequately
follow up results.
If a woman has
not had a Pap test during the previous 12 months, a Pap test may
be obtained as part of the routine pelvic examination. Health-care
providers should be aware that many women believe they have had
a Pap test when they actually have received only a pelvic examination,
and thus may report having had a recent Pap test. Therefore, in
STD clinics, a Pap test should be strongly considered during the
routine clinical evaluation of women who do not have clinical-record
documentation of having had a normal Pap test within the preceding
12--36 months.
A woman may
benefit from receiving printed information about Pap tests and a
report containing a statement that a Pap test was obtained during
her clinic visit. If possible, a copy of the Pap test result should
be provided to the patient for her records.
Follow-Up
Clinicians who
offer Pap test screening services are encouraged to use cytopathology
laboratories that report results using the Bethesda System of classification†††.
If the results of the Pap test are abnormal, care should be provided
according to the Interim Guidelines for Management of Abnormal
Cervical Cytology published by the National Cancer Institute
Consensus Panel (95). Appropriate follow-up of Pap tests
showing high-grade SIL always includes referral to a clinician who
can provide a colposcopic examination of the lower genital tract
and, if indicated, colposcopically directed biopsy. For patients
who have a Pap test indicative of low-grade SIL or ASCUS, follow-up
without colposcopy may be acceptable in some circumstances. Such
follow-up would involve repeat Pap tests every 4--6 months for 2
years until the results of three consecutive tests are negative.
If repeat tests show persistent abnormalities, colposcopy and directed
biopsy may be indicated. However, if compliance with follow-up is
in question, women with low-grade SIL or ASCUS may be considered
for colposcopy. If specific infections other than HPV are identified,
the patient should be reevaluated after appropriate treatment for
those infections. In all follow-up strategies using repeat Pap tests,
the tests not only must be negative but also must be interpreted
by the laboratory as "satisfactory for evaluation." Tests determined
by the laboratory to be "satisfactory but limited by..." in conjunction
with a diagnosis of "negative" or "within normal limits" are also
considered negative.
Another strategy
for management of patients with ASCUS Pap tests involves testing
for HPV DNA. If high-risk types of HPV DNA are detected, women with
ASCUS tests are referred immediately for colposcopy. Because many
public health clinics, including most STD clinics, cannot provide
clinical follow-up of abnormal Pap tests, women with Pap tests demonstrating
high grade SIL, persistent low-grade SIL, or ASCUS usually need
a referral to other local health-care providers or clinics for colposcopy
and biopsy. Clinics and health-care providers who offer Pap test
screening services but cannot provide appropriate colposcopic follow-up
of abnormal Pap tests should arrange referral to services in which
a) a patient will be promptly evaluated and treated and b) the results
of the evaluation will be reported to the referring clinic or health-care
provider. Clinics and health-care providers should develop protocols
that identify women who miss follow-up appointments so that these
women can be scheduled for repeat Pap tests, and they should reevaluate
such protocols routinely. Pap test results, type and location of
follow-up appointments, and results of follow-up should be clearly
documented in the clinic record. The establishment of colposcopy
and biopsy services in local health departments, especially in circumstances
where referrals are difficult and follow-up is unlikely, should
be considered.
††† The
Bethesda System for Reporting Cervical/Vaginal Cytologic Diagnoses
uses the terms "low-grade SIL" and "high-grade SIL" (95).
Low-grade SIL encompasses cellular changes associated with HPV and
mild dysplasia/cervical intraepithelial neoplasia 1 (CIN1). High-grade
SIL includes moderate dysplasia/CIN2, severe dysplasia/CIN3, and
carcinoma in situ/CIN3.
Other
Management Considerations
Other considerations
in performing Pap tests are as follows.
- The Pap test
is not a screening test for STDs.
- If a woman
is menstruating, a Pap test should be postponed, and the woman
should be advised to have a Pap test at the earliest opportunity.
- The presence
of a mucopurulent discharge should not delay the Pap test. The
test can be performed after careful removal of the discharge with
a saline-soaked cotton swab.
- Women who
have external genital warts do not need to have Pap tests more
frequently than women who do not have warts, unless otherwise
indicated.
- The sequence
of Pap testing in relation to other cervicovaginal specimens does
not appear to influence Pap test results or their interpretation.
Therefore, when other cultures or specimens are collected for
STD diagnoses, the Pap test can be obtained last.
- Women who
have had a hysterectomy do not require a routine Pap test unless
the hysterectomy was performed as a result of cervical cancer
or its precursor lesions. In this situation, women should be advised
to continue follow-up with the physician(s) who provided health
care at the time of the hysterectomy.
- Health-care
providers who receive basic retraining on Pap-test collection
and clinics that use simple quality assurance measures obtain
fewer unsatisfactory tests. The use of cytobrushes also improves
the number of satisfactory Pap tests.
- Emerging
data support the option of HPV testing for the triage of women
who have ASCUS Pap tests. However, experience is limited and studies
to define its value and cost-effectiveness are ongoing. The HPV
testing strategy may be most cost-effective when conducted as
"reflex testing," in which samples collected at the initial visit
can be tested for HPV after the Pap test results are available.
This approach requires the collection of a cervical swab placed
in liquid media (i.e., liquid-based cytology or collection of
a separate swab stored in HPV transport media).
- Liquid-based
cytology is an alternative to conventional Pap tests. It has a
higher sensitivity for detection of SIL and can facilitate HPV
testing in women with ASCUS. However, it may also have a lower
specificity, resulting in more false-positive tests and more administrative
and patient-related costs, which could reduce the cost-effectiveness
of cervical cancer screening.
Special
Considerations
Pregnancy
Pregnant women
should have a Pap test as part of routine prenatal care. A cytobrush
may be used for obtaining Pap tests in pregnant women, although
care should be taken not to disrupt the mucous plug.
HIV
Infection
Several studies
have documented an increased prevalence of SIL in HIV-infected women
(96). The following recommendations for Pap test screening
among HIV-infected women are consistent with other guidelines published
by the U.S. Department of Health and Human Services (21)
and are based partially on the opinions of professionals knowledgeable
in the care and management of cervical cancer and HIV infection
in women.
After obtaining
a complete history of previous cervical disease, HIV-infected women
should be provided a comprehensive gynecologic examination, including
a pelvic examination and Pap test, as part of their initial evaluation.
A Pap test should be obtained twice in the first year after diagnosis
of HIV infection and, if the results are normal, annually thereafter.
If the results of the Pap test are abnormal, care should be provided
according to the Interim Guidelines for Management of Abnormal
Cervical Cytology (97). Women who have a cytological
diagnosis of high-grade SIL or squamous cell carcinoma should undergo
colposcopy and directed biopsy. HIV infection is not an indication
for colposcopy in women who have normal Pap tests.
Sexually
Transmitted Diseases Treatment Guidelines 2002
http://www.cdc.gov/STD/treatment/TOC2002TG.htm
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