Human Papillomavirus and
HIV-Infected Women
November 2007
This slide set was developed by members of the Cervical
Cancer Screening Subgroup of the AETC Women's Health
and Wellness Workgroup:
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Laura Armas, MD; Texas/Oklahoma AETC
Susa Coffey, MD; AETC National Resource Center
Abigail Davis, MS, ANP, WHNP; Mountain Plains AETC
Rebecca Fry, MSN, APN; François-Xavier Bagnoud Center
Jamie Steiger, MPH; AETC National Resource Center
Other subgroup members and contributors include:
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Lori DeLorenzo, MSN, RN; Organizational Ideas
Karen A. Forgash, BA; AETC National Resource Center
Kathy Hendricks, RN, MSN; François-Xavier Bagnoud Center
Supriya Modey, MBBS, MPH; AETC National Resource Center
Andrea Norberg, MS, RN; AETC National Resource Center
Peter Oates, RN, MSN, ACRN, NP-C; François-Xavier Bagnoud Center
Pamela Rothpletz-Puglia, EdD, RD; François-Xavier Bagnoud Center
Jacki Witt, JD, MSN, WHNP; Clinical Training Center for Family Planning
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Learning Objectives
1. Define what human papillomavirus (HPV) is and
how it is transmitted
2. Explain the relationship between HPV, genital
warts, and cervical cancer
3. Describe the health risks associated with HIVHPV coinfection
4. Discuss screening for HPV and management of
women with HIV and HPV
5. Describe cultural competency issues related to
providing care for women with HPV-HIV
coinfection
3
General HPV Infection
 DNA virus
 Spread by direct skin-to-skin
contact, usually vaginal or anal sex
 Approximately 50% of sexually
active population infected during
lifetime
Credit: Stephen C. Harrison, PhD
 70% of infections cleared by immune system within 1
year
 Over 100 types of HPV
 Infection usually asymptomatic
 Requires monitoring by Pap smear and HPV DNA
testing (women over 30 or abnormal Pap smear)
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Types of HPV
 Oncogenic strains can lead to cancer of the
cervix, vulva, or anus (16, 18, 31, 33, 39, 45, 51,
52, 56, 58, 59, 68, 82 )
 Types 16 and 18 account for most cases of
cervical cancers in women
 Types 6 and 11 most commonly cause genital
warts
 Analysis of 932 specimens from women in 22
countries indicated prevalence of HPV DNA in
cervical cancers worldwide = 99.7%
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Epidemiology of HPV
 Prevalence of HPV among women ages 14-59 in
the United States was 26.8%
 Prevalence of HPV among HIV-infected women
may be upwards of 60%
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Normal Anatomy
7
Credit: Netter image reused with the permission of Elsevier Inc.
Anal Warts
Credit: STI AIDS Netherlands
Credit: Seattle STD/HIV Prevention Training
Center, University of Washington
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Vaginal & Perineal Warts
Credit: STI AIDS Netherlands
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Molluscum Contagiosum and Herpes
Simplex Virus
Credit: www.dermnet.com
Credit: Jean R. Anderson, MD
Reprinted from BC Medical Journal, December
2004; 46(10):512
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Treatment of Genital Warts
 Treatment directed at HPV-associated lesions
 Local removal (cryotherapy, electrocautery, laser
therapy, surgical excision)
 Topical application with various pharmacological
agents (Podofilox 0.5%, Imiquimod 5%,
podophyllin resin 10-25%)
 Removal of lesions probably reduces, but does
not eliminate infectiousness
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Cervical Warts
 Must rule out high-grade SIL in all women who
have cervical warts
 Usually visualized during colposcopy (not Pap
smear)
 Management of cervical warts should be done in
consultation with a specialist
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HPV-HIV Coinfection
 HIV-infected women have
higher rates of HPV infection
when compared with HIV
uninfected women with
similar risk factors
 WIHS
 HERS
 HIV-infected women are
more likely to be infected
with multiple subtypes of
HPV
 Multiple sub-type infections
increase rates of SIL
Credit: www.dermnet.com
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HPV-HIV Coinfection (continued)
HIV-infected women have (a):
 Compromised immune systems and
experience common infections such as HPV
 Higher prevalence of HPV
 More persistent forms of HPV
 Higher risk of being infected with more than
one type of HPV
 Higher rates of abnormal Pap smears
 Higher incidence of cervical cancer
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HPV and Immunosuppression
Inverse relationship between measures of immunity
and HPV for HIV-infected women
 As CD4 cell count drops (and viral load
increases), prevalence of HPV infection increase
 Studies show a higher rate of oncogenic HPV
infections in women with lower CD4 cell counts
Role of antiretroviral (ARV) therapy, immune
reconstitution, and HPV
 Jury still out…
 ARV therapy (so far) has not been shown to
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prevent progression of dysplasia
Screening for HPV in HIV-Infected Women
 A Papanicolaou or Pap test is used to screen for cervical
abnormalities due to HPV infection
 Two types of tests are
 Conventional cytology: detects dysplasia, but cannot be used to
test for HPV DNA
 Liquid cytology: detects dysplasia and allows for reflex HPV DNA
testing for high and low risk types
 Initial Pap test performed when first diagnosed with HIV
or when first present for care
 Repeat test 6 months later
 After two consecutive “normal” results, an HIV-infected
woman should have a Pap smear annually
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Grading Pap Smear Results
(Cervical cytology)
Normal
Negative for intraepithelial lesion or malignancy
ASC-US
Atypical squamous cells of undetermined significance
ASC-H
Atypical squamous cells – cannot exclude HSIL
LSIL
Low-grade squamous intraepithelial lesion
HSIL
High-grade squamous intraepithelial lesion
AGUS
Other – atypical glandular cells of undetermined
significant
SCC
Squamous cell carcinoma
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Management of Abnormal
Pap Results in HIV-infected
Women
Credit: Permission granted
from original source
Screen women using
liquid cytology
Normal
Repeat in
6 months.
After two
consecutive normal
results, screen
annually.
ASC-US –
ASC-US
3 Options
See next slide
cannot exclude
HSIL
Refer for
colposcopy
LSIL or HSIL
Refer for
colposcopy
Atypical
glandular
cells of
undetermined
significance
Refer for
colposcopy
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Management of ASC-US in HIV-infected
Women
ASC-US
Option 1: Perform HPV DNA testing
Option 2: Repeat Pap Smear
Option 3: Refer for colposcopy
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Role of HPV-DNA Testing
In managing an abnormal result
(ASC-US):
In performing routine screening
for cervical cancer as an adjunct
to Pap smear:
 NYS AIDS Institute – no role for
HPV-DNA testing
 American Society for Colposcopy
and Cervical Pathology (ASSCP) –
used to triage ASC-US result
 American College of Obstetricians
and Gynecologists (ACOG) – used
to triage ASC-US result
 American Cancer Society (ACS)
– approved for routine use in
women > 30 years
 ACOG -approved for routine use
in women > 30 years
 USPSTF – insufficient evidence
to recommend for or against
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HIV and the HPV vaccine
 HPV vaccine (Gardasil®)
 Protects against the four types of HPV that cause the most cases of
cervical cancer and genital warts (16, 18, 6, 11)
 Vaccine was well studied and appears to be safe, effective, and
does not appear to cause any serious side effects
 HPV vaccine has not been tested on HIV-infected women
or girls
“The presence of immunosuppression, like that experienced in patients with
HIV infection, is not a contraindication to the quadrivalent HPV vaccine.
However, the immune response may be smaller in the immunocompromised
patient than in immunocompetent patients.” -ACOG
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HPV Infection and Detection by Anal
Pap Smears
 HIV-infected men and women are at higher risk of
developing squamous cell cancer of the anus (especially
MSM)
 It is possible that screening HIV-infected patients with
anal Pap smears will decrease the morbidity and
mortality associated with anal cancers and dysplasia
 Evidence in support of performing routine anal Pap
smears not available…yet, but some guidelines
recommend anal Pap tests at baseline and annually for:
 MSM
 Any patient with history of anogenital warts
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 Women with abnormal cervical or vulvar histology
Providing Culturally Competent Care
The following factors can influence a woman’s
understanding of HPV, cervical cancer, and need for
regular screening:
 Language and literacy level
 Cultural and social background and it’s impact on her
understanding of health, illness, and the female anatomy
 Comfort with discussing sexual health issues
 Comfort and previous experience with pelvic exams and
Pap smears
 Ability to follow-up with colposcopy
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Cultural Competency Discussion
 Incidence cervical cancer for black women is 1.5
times higher than that for white women
 Incidence for Hispanic women also higher than
that for white women
 Death rates for black women were twice those for
white women
What are the clinical care implications for HIV-infected
women of color based on this epidemiological information?
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Pearls of Wisdom
 Genital warts typically indicate infection with low-risk types
of HPV in uninfected women, but HIV-infected women can
be infected with more than one type of HPV
 Healthcare workers may want to use liquid-based cytology
for a Pap smear with a reflex for HPV-DNA testing to avoid
having to repeat exams if the results of the Pap smear are
abnormal
 HIV-infected women who are symptomatic or have low
CD4 cell counts may be candidates for more frequent Pap
screenings (ie, more than annually)
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Conclusions
 HPV infections are more common, more virulent, and
more persistent in HIV-infected women
 Pap smears are the standard of care in HIV-infected
women for screening for cervical abnormalities that
accompany HPV infection
 Pap smears should be performed upon diagnosis with
HIV and then 6 months later
 If both are normal, repeat Pap smears annually
 For HIV-infected women with abnormal Pap results,
HPV-DNA can be a useful tool to help triage women for
colposcopy
 In most clinical situations, women with abnormal Pap
results (ASC-US or above) will need colposcopy as
soon as possible with close follow-up of results
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Helpful Resources
 AETC National Resource Center (NRC), www.aidsetc.org
 Clinical Manual for Management of the HIV-Infected Adult
 Health Resources and Services Administration HIV/AIDS Bureau,
http://hab.hrsa.gov/
 A Guide to the Clinical Care of Women with HIV/AIDS
 Centers for Disease Control and Prevention,
http://www.cdc.gov/std/hpv/default.htm
 Human Papillomavirus: HPV Information for Clinicians
 STD Treatment Guidelines 2006
 AIDSMAP, http://www.aidsmap.com/cms1032598.asp
 American Society for Colposcopy and Cervical Pathology,
http://www.asccp.org/hpv.shtml#provider
 Association of Reproductive Health Professionals,
http://www.arhp.org/healthcareproviders/cme/webcme/index.cfm
 HIVInsite, http://hivinsite.ucsf.edu/InSite?page=kb-00&doc=kb-06-04-01
 Planned Parenthood,
http://www.plannedparenthood.org/sexual-health/std/hpv.htm
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