Human
Papillomavirus Infection
TreatmentGenital
WartsMore
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 STDsWomen
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. RecommendationsAt
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
ConsiderationsPregnancy 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 Otros
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