Human Papillomavirus (HPV) Infection

Approximately 150 types of HPV have been identified, at least 40 of which infect the genital area (1194). The majority of HPV infections are self-limited and are asymptomatic or unrecognized. Sexually active persons are usually exposed to HPV during their lifetime (838,1195,1196). Oncogenic, high-risk HPV infection (e.g., HPV types 16 and 18) causes the majority of cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers and precancers (1197), whereas other HPV infection (e.g., HPV types 6 and 11) causes genital warts and recurrent respiratory papillomatosis. Persistent oncogenic HPV infection is the strongest risk factor for development of HPV-attributable precancers and cancers. A substantial proportion of cancers and anogenital warts are attributable to HPV in the United States. An estimated 34,800 new HPV-attributable cancers occurred every year during 2012–2016 (1198). Before HPV vaccines were introduced, approximately 355,000 new cases of anogenital warts occurred every year (1199).

Prevention

HPV Vaccines

Three HPV vaccines are licensed in the United States: Ceravrix, a 2-valent vaccine (2vHPV) that targets HPV types 16 and 18; Gardasil, a 4-valent vaccine (4vHPV) that targets HPV types 6, 11, 16, and 18; and Gardasil 9, a 9-valent vaccine (9vHPV) that targets HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. Types 16 and 18 account for 66% of all cervical cancers, whereas the five additional types targeted by the 9-valent vaccine account for 15%. Types 6 and 11 cause >90% of genital warts. Only 9vHPV vaccine is available in the United States.

ACIP recommendations for HPV vaccination (https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html) include the following:

• Routine HPV vaccination for all adolescents at age 11 or 12 years.
• Administering vaccine starting at age 9 years.
• Catch-up vaccination through age 26 years for those not vaccinated previously.
• Not using HPV vaccination for all adults aged >26 years. Instead, shared clinical decision-making between a patient and a provider regarding HPV vaccination is recommended for certain adults aged 27–45 years not vaccinated previously.
• A 2-dose vaccine schedule (at 0- and 6–12-month intervals) is recommended for persons who initiate vaccination before their 15th birthday.
• A 3-dose vaccine schedule (at 0-, 1–2-, and 6-month intervals) for immunocompromised persons regardless of age of initiation.

HPV vaccines are not recommended for use in pregnant women. HPV vaccines can be administered regardless of history of anogenital warts, abnormal Pap test or HPV test, or anogenital precancer. Women who have received HPV vaccine should continue routine cervical cancer screening (see Cervical Cancer). HPV vaccine is available for eligible children and adolescents aged <19 years through the Vaccines for Children (VFC) program (additional information is available at https://www.cdc.gov/vaccines/programs/vfc/index.html or by calling CDC INFO 800-232-4636). For uninsured persons aged <19 years, patient assistance programs are available from the vaccine manufacturers. Prelicensure and postlicensure safety evaluations have determined that the vaccine is well tolerated. With >120 million doses of HPV vaccines distributed in the United States, robust data demonstrate that HPV vaccines are safe (https://www.cdc.gov/vaccinesafety). Impact-monitoring studies in the United States have demonstrated reductions of genital warts as well as the HPV types contained within the quadrivalent vaccine (1200–1203). Settings that provide STI services should either administer the vaccine to eligible clients within the routine and catch-up age groups through age 26 years who have not started or completed the vaccine series, or link these persons to another facility equipped to provide the vaccine. Clinicians providing services to children, adolescents, and young adults should be knowledgeable about HPV and the vaccine (https://www.cdc.gov/vaccines/who/teens/for-hcp/hpv-resources.html). HPV vaccination has not been associated with initiation of sexual activity or sexual risk behaviors (1204,1205).

Abstaining from sexual activity is the most reliable method for preventing genital HPV infection. Persons can decrease their chances of infection by practicing consistent and correct condom use and limiting their number of sex partners. Although these interventions might not fully protect against HPV, they can decrease the chances of HPV acquisition and transmission.

Diagnostic Considerations

HPV tests are available for detecting oncogenic types of HPV infection and are used in the context of cervical cancer screening and management or follow-up of abnormal cervical cytology or histology (see Cervical Cancer). These tests should not be used for male partners of women with HPV or women aged <25 years, for diagnosis of genital warts, or as a general STI test.

Application of 3%–5% acetic acid, which might cause affected areas to turn white, has been used by certain providers to detect genital mucosa infected with HPV. The routine use of this procedure to detect mucosal changes attributed to HPV infection is not recommended because the results do not influence clinical management.

Treatment

Treatment is directed to the macroscopic (e.g., genital warts) or pathologic precancerous lesions caused by HPV. Subclinical genital HPV infection typically clears spontaneously; therefore, specific antiviral therapy is not recommended to eradicate HPV infection. Precancerous lesions are detected through cervical cancer screening; HPV-related precancer should be managed on the basis of existing guidance (see Cervical Cancer).

Counseling

Key Messages for Persons with Human Papillomavirus Infection

When counseling persons with anogenital HPV infection, the provider should discuss the following:

• Anogenital HPV infection is common. It usually infects the anogenital area but can infect other areas, including the mouth and throat. The majority of sexually active persons get HPV at some time during their lifetime, although most never know it.
• Partners tend to share HPV, and it is not possible to determine which partner transmitted the original infection. Having HPV does not mean that a person or his or her partner is having sex outside the relationship.
• Persons who acquire HPV usually clear the infection spontaneously, meaning that HPV becomes undetectable with no associated health problems.
• If HPV infection persists, genital warts, precancers, and cancers of the cervix, anus, penis, vulva, vagina, head, or neck might develop.
• Discussion of tobacco use, and provision of cessation counseling, is important because of its contribution to the progression of precancer and cancer.
• The types of HPV that cause genital warts are different from the types that can cause cancer.
• Many types of HPV are sexually transmitted through anogenital contact, mainly during vaginal and anal sex. HPV also might be transmitted during oral sex and genital-to-genital contact without penetration. In rare cases, a pregnant woman can transmit HPV to an infant during delivery.
• Treatments are available for the conditions caused by HPV but not for the virus itself.
• Having HPV does not make it harder for a woman to get pregnant or carry a pregnancy to term. However, certain precancers or cancers that HPV can cause, and the surgical procedures needed to treat them, can affect a woman’s ability to get pregnant or carry a pregnancy to term.
• No HPV test can determine which HPV infection will become undetectable and which will persist or progress to disease. However, in certain circumstances, HPV tests can determine whether a woman is at increased risk for cervical cancer. These tests are not for detecting other HPV-related problems, nor are they useful for women aged <25 years or men of any age.

Prevention

• Three HPV vaccines can prevent diseases and cancers caused by HPV. The 2vHPV, 4vHPV, and 9vHPV vaccines protect against the majority of cervical cancer cases, although the 4vHPV and 9vHPV vaccines also protect against the majority of genital warts. Only 9vHPV vaccine is available in the United States. HPV vaccines are safe and effective and are recommended routinely for adolescents aged 11–12 years. Catch-up vaccination is also recommended for older adolescents and young adults through age 26 years (https://www.cdc.gov/hpv/hcp/index.html). Shared clinical decision-making is recommended regarding HPV vaccination for certain adults aged 27–45 years who are not adequately vaccinated per guidance (https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6832a3-H.pdf).
• Condoms used consistently and correctly can lower the chances of acquiring and transmitting HPV and developing HPV-related diseases (e.g., genital warts or cervical cancer). However, because HPV can infect areas not covered by a condom, condoms might not fully protect against HPV.
• Limiting the number of sex partners can reduce the risk for HPV. However, even persons with only one lifetime sex partner can get HPV.
• Abstaining from sexual activity is the most reliable method for preventing genital HPV infection.

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