HPV A guide for practitioners - PapScreen

1 In 2017, there will be changes to how often cervical screening takes place and the age groups for cervical screening. Until then PapScreen Victoria encourages women to continue having Pap tests every two years. HPV A guide for practitioners Human papillomavirus HPV testing post-HSIL treatment HPV TEST OF CURE. Human papillomavirus (HPV) is critical in the pathogenesis of NHMRC Guidelines for the management of asymptomatic COMMON SCENARIOS FOR PATIENTS WITH HSIL. cervical cancer. We now have reliable tests to detect HPV DNA. women with screen detected abnormalities (2005) recommend Scenario one Genital HPV infection is usually transient and most often that women treated for biopsy-confirmed HSIL should be 4 6 months after treatment Pap test and colposcopy asymptomatic.

2 It is highly contagious and most people acquire followed up with a Pap test and colposcopy four to six months Both negative infection within a few years of becoming sexually active. after treatment. 12 months after treatment Pap test and HPV test Of the 50 genital HPV types, 15 are classified as high-risk' Cervical cytology plus HPV testing should then be performed 12 Both negative as they are associated with ano-genital cancer (including months post treatment, and annually thereafter until both tests 24 months after treatment Pap test and HPV test are negative on two consecutive occasions. These women can Both negative squamous and adenocarcinoma of the cervix).

3 Then return to the routine cervical screening interval. The high-risk HPV types 16 and 18 cause 70% or more of Outcome Return to two-yearly screening. cervical cancers. However, while HPV is an extremely common 4 to 6 months after treatment Pap test and colposcopy Scenario two genital infection, ano-genital cancer is actually a rare outcome Both negative 4 6 months after treatment Pap test and colposcopy of its acquisition. 12 months after treatment Pap test and HPV test Both negative The immune system clears the virus within one to two years in Both negative 12 months after treatment Pap test and HPV test the majority of those infected with genital HPV, but persistent 24 months after treatment Pap test and HPV test Pap test negative, HPV test positive infection with a high-risk HPV type (especially HPV 16) is Both negative associated with a significantly elevated risk of developing high- Outcome Pap test and HPV test should be conducted 12 months grade cellular abnormalities on the cervix.

4 If at any point the Pap test is reported as HSIL, later and then annually until both tests are negative on two refer back for colposcopy. consecutive occasions. There are many low-risk' HPV types, the most significant of which are types 6 and 11 as these are responsible for around If at any point the Pap test is reported as LSIL, Scenario three 90% of genital warts. Low risk HPV types do not cause ano- repeat both tests in 12 months. 4 6 months after treatment Pap test and colposcopy genital cancers but are often associated with low-grade Both negative If at any point the HPV test is positive, even in the absence squamous intraepithelial lesions (LSIL) on Pap tests.

5 An LSIL of HSIL, repeat both tests in 12 months. 12 months after treatment Pap test and HPV test Pap test report is often indicative of an acute HPV infection. Pap test positive (LSIL), HPV test negative Medicare rebates for HPV testing HPV tests following Outcome Pap test and HPV test should be conducted 12 months HPV testing treatment of a biopsy-confirmed high-grade lesion are later and then annually until both tests are negative on two The purpose of HPV testing is to detect the presence of covered by Medicare (item number 69418). Medicare will consecutive occasions. high-risk HPV types associated with high-grade squamous pay for two HPV tests in an on-going 24 month period (until intraepithelial lesions (HSIL) and cervical cancer.)

6 HPV testing Scenario four two consecutive negative Pap and HPV tests have been is very sensitive and is considered a useful tool for predicting 4 6 months after treatment Pap test and colposcopy reported, at which point the woman can return to Pap tests which women with a history of HSIL are at greatest risk of Both negative at the routine interval). recurrence. 12 months after treatment Pap test and HPV test Need more information? Pap test negative, HPV test positive NHMRC guidelines do not currently recommend HPV testing for women with LSIL changes. While these women can be Women and health professionals who have 24 months after treatment Pap test and HPV test offered HPV testing at their own expense, it is important to note questions about Pap tests, HPV or cervical cancer Pap test positive (HSIL), HPV test positive that testing positive for a high-risk HPV type will not necessarily can visit or call the Outcome Refer to colposcopy as per NHMRC guidelines (2005).

7 Change the recommended management and may only serve to Cancer Council on 13 11 20. The above four scenarios are based on the NHMRC guidelines, but do not take exacerbate patient anxiety. into account every possible situation. Doctors should use discretion in situations not outlined above. Genital HPV. Explaining the facts to women SUGGESTED PHRASES TO EXPLAIN HPV TO WOMEN CHECK LIST FOR EXPLAINING HPV. What is genital HPV? HPV and sexual history Reassure women that low-grade changes are common, HPV is a virus that is passed on during genital skin-to-skin People can have HPV for a long time without ever knowing it.

8 Usually transient and can safely be monitored for contact. It may have been acquired many years ago. 12 months. It is extremely common in men and women who have ever Do I need to abstain from sex if I have HPV? had sex. There is no reason to stop having sex if your Pap test shows Normalise the virus: HPV has been referred to as the Some types of HPV cause genital warts, but most HPV HPV-related changes. common cold of sexual activity'. Using this analogy can infection is invisible. Condoms and HPV be useful when explaining why it is seldom necessary to HPV is usually cleared by the body's immune system in one Condoms offer limited protection against HPV as they do refer a woman for colposcopy after an initial LSIL report.

9 To two years. not cover all of the genital skin. However, they do provide It is best to give the body's immune system a chance to HPV and cervical cancer excellent protection against infections such as chlamydia resolve infection first. Although most HPV infection is cleared from the body, some and are recommended in new sexual relationships. types (especially HPV types 16 and 18) are more likely to be Should I have an HPV test? Use the terminology low-grade' and high-grade'. persistent and can then cause cell changes on the cervix. HPV tests are currently only recommended for women abnormalities. These cell changes can usually be found on Pap tests who have had treatment for a confirmed high-grade and can be treated.

10 If left untreated, they may develop into Always try to provide written information. PapScreen abnormality. In these cases we look for clearance of HPV so cervical cancer. that women can return to the routine Pap screening interval. Victoria has brochures on HPV for women. Some HPV types (especially types 6 and 11) cause genital Medicare covers the cost of HPV testing for these women. Explain the process to enable the return to two-yearly warts. These do not cause cancer. If the test is taken in other circumstances it will cost around $60 to $100 depending on which laboratory it is sent to. screening for women who have had a HSIL before the HPV transmission and Pap tests sequence begins.