Human Papilloma Virus Flashcards
What are the oncogenic HPV types associated with cervical cancer?
HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59
HPV68 is considered probably oncogenic.
What percentage of cervical cancers is attributed to HPV16?
Approximately 53% to 73%
HPV18 accounts for another 12% to 21%.
What is the relationship between HPV infection and cervical cancer?
HPV infection is the major risk factor for cervical cancer development.
How much higher is the rate of cervical cancer in women with HIV compared to the general population?
3 to 4 times higher
95% confidence interval [CI], 3.13–3.70.
What factors increase the relative risk of cervical cancer in women with HIV?
Decreasing CD4 T lymphocyte (CD4) cell counts.
What is the incidence rate of invasive cervical cancer (ICC) in women with HIV?
47.7 per 100,000 person-years.
What is the significance of CD4 counts in relation to anal cancer risk in people with HIV?
Low CD4 counts are associated with increased risk of anal cancer.
What is the cumulative 4-year progression from high-grade squamous intraepithelial lesion (HSIL) to anal cancer estimated in the ANCHOR study?
1.8%.
What types of HPV are responsible for the majority of anogenital warts?
Non-oncogenic HPV types 6 or 11.
What are the principal clinical manifestations of mucosal HPV infection?
Genital, anal, and oral warts; CIN; VIN; VAIN; AIN; anogenital squamous cell cancers; cervical adenocarcinomas.
What is the recommended age for routine HPV vaccination?
Age 11 or 12 years.
How many doses of the 9-valent HPV vaccine are recommended for people with HIV?
Three doses.
Is HPV vaccination recommended during pregnancy?
No.
What is the main purpose of the HPV vaccine?
To prevent HPV infection.
What are the FDA-approved HPV vaccines available in the U.S.?
Bivalent, quadrivalent, and 9-valent.
What is the indication for the 9-valent HPV vaccine?
Prevention of cervical, vaginal, vulvar, and anal cancer; genital warts; oropharyngeal and other head and neck cancers.
What is the significance of shared clinical decision-making regarding HPV vaccination for adults aged 27 to 45 years?
It is recommended for those not adequately vaccinated and at risk for new HPV infection.
What did studies show about the immune response to HPV vaccination in people with HIV?
Immune responses appear stronger among those with higher CD4 counts and suppressed HIV viral loads.
What type of lesions may indicate a higher risk for anal cancer in people with HIV?
High-grade anal intraepithelial neoplasia (AIN).
True or False: HPV vaccination prevents all HPV types that may lead to cervical cancer.
False.
What is the relationship between ART and the incidence of HPV and CIN?
Effective ART use is associated with decreased incidence, persistence, and progression of HPV and CIN.
What is the incidence rate of HIV among youth who acquired it perinatally?
100 person-years of 15 (10.9–29.6)
What is the incidence rate of HIV among youth who were exposed but uninfected?
100 person-years of 2.9 (0.4–22.3)
What is the recommendation for people with HIV who have been vaccinated regarding cervical cancer screening?
Continue routine cervical cancer screening
Why should people with HIV continue cervical cancer screening even after vaccination?
The vaccine does not prevent all HPV types and may be less effective in those with low CD4 counts
What type of condoms are recommended for preventing HPV transmission?
Male latex condoms
What is the efficacy of consistent male condom use in women regarding oncogenic HPV infection?
Associated with 70% lower incidence
What is the association of consistent condom use among heterosexual men with no steady sex partner?
50% lower odds of HPV infection of the penis
What are the benefits of male condoms besides preventing HPV?
Reducing risk of nearly all STIs, including HIV
What alternative should be considered when male condoms cannot be used properly?
Female condom (e.g., FC1 or FC2 Female Condom)
How does male circumcision impact oncogenic HPV infection rates?
Reduces rates of oncogenic HPV infection of the penis
What is the evidence regarding circumcision and HPV infection in people with HIV?
Effects may be less protective in people with HIV than in those without
What are the cervical cancer screening recommendations for people with HIV aged 21 to 29 years?
Cervical cytology at the time of initial diagnosis
What is the rationale for starting cervical cancer screening at age 21 for people with HIV?
To provide a 3- to 5-year window before age 25 when risk exceeds that of the general population
What should be done if cytology reveals ASC-US and reflex hr-HPV testing is positive?
Refer for colposcopy
What is the recommendation for cervical cancer screening for people with HIV aged 30 years and older?
Continue screening throughout their lifetime
What types of tests are acceptable for cervical cancer screening in people with HIV aged 30 years and older?
Cytology only or cytology and HPV co-testing
What is the absolute incidence of invasive cervical cancer (ICC) among women with HIV under 25 years?
Exceedingly low
What are the possible cervical cytology results?
- Normal (negative for intraepithelial lesion or malignancy) * LSIL or CIN 1 * HSIL or CIN 2, 3 * ASC-US * ASC-H * AGC
What is the prevalence of positive HPV screening tests in women with HIV compared to the general population?
Several-fold more common
What does primary oncogenic HPV screening aim to achieve?
Reduce unnecessary colposcopies
What is the recommendation for patients with a history of high-grade CIN after hysterectomy?
Annual vaginal cuff cervical cytology
What is the recommendation for screening for anal cancer in people with HIV?
Annual assessment of anal symptoms and screening for anal HSIL
What should MSM and transgender women below the age of 35 undergo for anal cancer screening?
Digital anorectal examination (DARE) and standard anoscopy
What is recommended for MSM and transgender women aged 35 and above with symptoms?
Refer to high-resolution anoscopy (HRA)
What is the classification of VAIN?
Parallels that of the cervix: VAIN 1, VAIN 2, and VAIN 3
What is the recommendation for vulvar cancer screening?
Biopsy or referral when lesions suspicious for VIN or cancer are identified
What does the term ‘co-testing’ refer to?
Combined cytology and high-risk HPV (hr-HPV) testing
What does ‘primary HPV testing’ refer to?
hr-HPV testing alone
What does HRA stand for?
High-resolution anoscopy
HRA identifies anal HSIL and allows for treatment to prevent progression to anal cancer.
What is the purpose of HRA?
Identifies anal HSIL and enables treatment to prevent progression to anal cancer
Requires biopsy for histopathologic confirmation.
What is standard anoscopy?
Visualization of the anal canal and perianal region through an anoscope without application of 5% acetic acid or Lugol’s iodine
Used to identify lesions and rule out invasive cancer.
What additional tools are used in HRA compared to standard anoscopy?
5% acetic acid and Lugol’s iodine
HRA allows greater precision in identifying flat lesions.
At what age should MSM and transgender women with HIV begin screening for anal HSIL?
Age 35
This recommendation is based on the incidence of anal cancer.
At what age should cisgender women and other persons with HIV begin screening for anal cancer?
Age 45
Screening guidelines vary based on sex and HIV risk group.
What factors increase the risk of anal cancer in people with HIV?
- Older age
- Longer known duration of immune suppression and HIV infection
- History of AIDS
- Smoking
- Positive HPV16 or 18 status
- Higher grade of cytologic abnormality
Individuals meeting these criteria should be screened and referred for HRA.
What screening methods can be used for anal cancer?
- Anal cytology alone
- hr-HPV co-testing
HRA and treatment should be available for effective screening.
What are the recommendations regarding HPV testing in screening?
No FDA-cleared anal HPV tests are available; use only CLIA-certified laboratories
HPV testing should not be used for screening, diagnosis, or management of visible genital/oral warts.
What is the recommendation from the International Anal Neoplasia Society regarding anal cancer screening for people with HIV?
Screen MSM and transgender women aged more than 35 years with HIV and all others aged 45 years or above with HIV
This aligns with NIH OAR guidelines.
What is the treatment recommendation if HSIL is identified on biopsy?
Treatment of the lesion should be performed to reduce the incidence of anal cancer among people with HIV
This is classified as a strong recommendation (AI).
What methods exist for diagnosing genital and oral warts?
Visual inspection and biopsy if uncertain
No data supports HPV testing for screening or management.
What is the recommended treatment for uncomplicated external warts that can be easily identified by patients?
- Topical imiquimod (5% cream)
- Topical podofilox (0.5% solution or gel)
- Topical sinecatechins (15% ointment)
- Topical cidofovir (1%)
Each treatment has specific application instructions and duration.
What are provider-applied treatment options for complex or multicentric lesions?
- Cryotherapy
- TCA and BCA
- Intralesional cidofovir
- Surgical treatments
Laser surgery is an option but is usually more expensive.
What considerations should be made during pregnancy for treating warts?
Topical treatments and ablative therapies can be used
Obstetrical management should not change unless extensive condylomata might impede vaginal delivery.
What are the key differences in cancer survival rates between people with HIV and the general population?
Cancer-specific survival following treatment of anal cancer and oropharyngeal cancer was similar; cervical cancer survival was lower in women with HIV
HIV is associated with higher risk of relapse and cervical cancer mortality.
How do genital warts in people with HIV differ from those in immunocompetent individuals?
People with HIV may have larger or more numerous warts, may not respond as well to therapy, and may have more frequent recurrences after treatment.
Are genital warts life-threatening?
No, genital warts are not life-threatening and may regress without therapy.
What should be done for refractory lesions in people with HIV?
Histologic diagnosis should be obtained to confirm the absence of high-grade disease.
What is the recommended treatment for uncomplicated external warts?
Patient-applied treatments are recommended.
What is Imiquimod and how should it be applied?
Imiquimod (5% cream) is a topical cytokine inducer applied at bedtime on 3 nonconsecutive nights per week for up to 16 weeks.
How should Podofilox be applied for genital warts?
Podofilox 0.5% solution or gel should be applied twice a day for 3 days, followed by 4 days of no therapy.
What is the application frequency for sinecatechins?
Sinecatechins (15% ointment) should be applied three times daily for up to 16 weeks.
What are provider-applied treatments for complex lesions?
Cryotherapy, trichloroacetic acid (TCA), bichloroacetic acid (BCA), and surgery.
What is cryotherapy and how is it performed?
Cryotherapy destroys lesions by thermal-induced cytolysis, applied until each lesion is thoroughly frozen, repeated every 1 to 2 weeks.
What is the action of TCA and BCA on warts?
Both act as caustic agents to destroy wart tissue.
What is the recommended management for CIN in people with HIV?
Managed according to ASCCP guidelines.
What treatments are available for biopsy-confirmed high-grade CIN?
- Ablation (cryotherapy, laser vaporization, electrocautery) * Excisional methods (loop electrosurgical excision, laser conization, cold knife conization)
What is the recommended follow-up for high-grade CIN in adolescents and young women?
Close observation should be considered due to higher progression and recurrence.
What is the treatment approach for recurrent high-grade CIN?
Diagnostic excisional methods are recommended.
What are the management guidelines for vulvar and vaginal cancer?
Must be individualized in consultation with a specialist, following NCCN guidelines.
What is a reasonable first-line treatment for anal HSIL?
Office-based hyfrecation.
What is the effect of early ART initiation on HPV-related disease?
Early ART initiation is clinically beneficial in reducing risk of AIDS and opportunistic infections.
What are common adverse events following treatment for CIN?
- Pain * Discomfort * Intraoperative hemorrhage * Postoperative hemorrhage * Infection * Cervical stenosis
What should be monitored during treatment for genital warts?
Physical examination to detect toxicity, persistence, or recurrence.
What treatment is recommended for recurrent genital warts?
Retreatment with any of the modalities previously described should be considered.
What is the recommendation for monitoring after therapy for cervical disease?
Follow ASCCP guidelines.
What is the recommendation for pregnant individuals with genital warts?
Managed by an interdisciplinary team of specialists.
What treatments should not be used during pregnancy?
Podofilox should not be used.
What is the presumed mechanism of juvenile-onset recurrent respiratory papillomatosis?
Transmission of genital HPV6 and 11 from vaginal secretions at delivery.
What is the management recommendation for pregnant individuals with abnormal cervical cytology results?
Colposcopy and cervical biopsy of suspicious lesions.
What is the recommendation regarding HPV vaccination during pregnancy?
HPV vaccination is not recommended during pregnancy.
What should be done for suspected cervical cancer during pregnancy?
Refer to a gynecologic oncologist for definitive diagnosis and treatment.
