Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents

The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

Human Papillomavirus Disease

Last Updated: November 29, 2018; Last Reviewed: November 29, 2018

Recommendations for Cervical Cancer Screening for Women with HIV Infection
Women with HIV Aged <30 Years:
  • If younger than 21 years, known to have HIV infection or newly diagnosed HIV infection, and sexually active, screen within 1 year of onset of sexual activity regardless of mode of HIV infection.
  • Women with HIV infection aged 21 to 29 years should have a Pap test following initial diagnosis of HIV.
  • Pap test should be done at baseline and every 12 months (BII).
  • Some experts recommend a Pap test at 6 months after the baseline test (CIII)
  • If results of 3 consecutive Pap tests are normal, follow-up Pap tests can be performed every 3 years (BII)
  • Co-testing (Pap test and HPV test) is not recommended for women younger than 30 years.
Women with HIV Aged ≥30 Years
Pap Testing Only:
  • Pap test should be done at baseline and every 12 months (BII).
  • Some experts recommend a Pap test at 6 months after the baseline test (CIII).
  • If results of 3 consecutive Pap tests are normal, follow-up Pap tests can be performed every 3 years (BII).
Or:

Pap Test and HPV Co-Testing:
  • Pap test and HPV co-testing should be done at baseline (BII).
  • If result of the Pap test is normal and HPV co-testing is negative, follow up Pap test and HPV co-testing can be performed every 3 years (BII).
  • If the result of the Pap test is normal but HPV co-testing is positive:
    Either
    • Follow up test with Pap test and HPV co-testing should be performed in 1 year.
    • If the 1-year follow-up Pap test is abnormal, or HPV co-testing is positive, referral to colposcopy is recommended.
    Or:
    • Perform HPV genotyping.
      • If positive for HPV-16 or HPV-18, colposcopy is recommended.
      • If negative for HPV-16 and HPV-18, repeat co-test in 1 year is recommended. If the follow-up HPV test is positive or Pap test is abnormal, colposcopy is recommended
Or:

Pap Test and HPV16 or HPV16/18 Specified in Co-Testing:
  • Pap test and HPV 16 or 16/18 co-testing should be done at baseline (BII).
  • If result of the Pap test is normal, and HPV 16 or 16/18 co-testing is negative, follow-up Pap test and HPV co-testing can be performed every 3 years (BII).
  • If initial test or follow-up test is positive for HPV 16 or 16/18, referral to colposcopy is recommended (BII).

Recommendations for Preventing Human Papillomavirus Infections
Preventing First Episode of HPV Infection
Indications for HPV Vaccination:
  • HIV-infected; aged 13 to 26 years (AIII)
Note: Please refer to Pediatric OI guidelines for vaccination of boys and girls younger than age 13.

Vaccination Schedules

HPV recombinant vaccine 9 valent (Types 6, 11, 16, 18, 31, 33, 45, 52, 58) 0.5 mL IM at 0, 1 to 2, and 6 months (AIII)

  • For patients who have completed a vaccination series with the recombinant bivalent or quadrivalent vaccine, many experts would give additional full series of vaccination with recombinant 9-valent vaccine, but there are no data to define who might benefit or how cost effective this approach might be (CIII)
Treating Condyloma Acuminata (Genital Warts)

Note: Patients with HIV infection may have larger or more numerous warts, may not respond as well to therapy for genital warts, and have a higher risk of recurrence after treatment than individuals who are HIV negative. More than one treatment option maybe required for refractory or recurrent lesions. Intra-anal, vaginal, or cervical warts should be treated and managed by a specialist.

Patient-Applied Therapy
For Uncomplicated External Warts that can be Easily Identified and Treated by the Patient:
  • Imiquimod 5% cream: Apply to lesions at bedtime on 3 non-consecutive nights a week, and wash the treatment area with soap and water 6 to 10 hours after application (BII), repeating the cycle until lesions are no longer seen, for up to 16 weeks, or
  • Sinecatechins 15% ointment: Apply to area 3 times daily for up to 16 weeks, until warts are not visible (BIII).
Provider-Applied Therapy
For Complex or Multicentric Lesions, Lesions Inaccessible to Patient-Applied Treatments, or Patient/Provider Preference:
  • Cryotherapy (liquid nitrogen or cryoprobe): Apply until each lesion is thoroughly frozen; repeat every 1 to 2 weeks for up to 4 weeks until lesions are no longer visible (BIII). Some specialists allow the lesion to thaw, and then freeze a second time in each session (BIII).
  • TCA or BCA cauterization: 80% to 90% aqueous solution, apply to warts only and allow the area to dry until a white frost develops. If an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate, or liquid soap to remove unreacted acid. Repeat treatment weekly for up to 6 weeks until lesions are no longer visible (BIII).
  • Surgical excision (BIII) or laser surgery (CIII) can be performed for external or anal warts.
Key to Acronyms: BCA = bichloroacetic acid; HPV = human papillomavirus; IM = intramuscular; OI = opportunistic infection; TCA = trichloroacetic acid

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