Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children

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

Last Updated: November 6, 2013; Last Reviewed: November 6, 2013

Panel's Recommendations for Human Papillomavirus
Panel's Recommendations
  • HIV-infected individuals should use latex condoms during every act of sexual intercourse to reduce the risk of exposure to sexually transmitted pathogens, including human papillomavirus (HPV) (AII).
  • Ideally, HPV vaccine should be administered before an individual becomes sexually active (AIII).
  • HPV vaccination is recommended in HIV-infected females and males aged 11 to 12 (AIII) and 13 to 26 (BIII) years. HPV vaccination also can be administered to HIV-infected males and females aged 9 to 10 years. The bivalent and quadrivalent vaccines are approved for females and the quadrivalent vaccine is approved for males. 
  • Sexually active female adolescents who are HIV-infected should have routine cervical cancer screening whether or not they have been vaccinated (AIII).
  • HIV-infected female adolescents who have initiated sexual intercourse should have cervical screening cytology (liquid-based or Pap smear) obtained twice at 6-month intervals during the first year after diagnosis of HIV infection, and if the results are normal, annually thereafter (AII). A Pap smear should be performed within 1 year of onset of sexual activity, regardless of age or method of HIV transmission (BIII).
  • If the results of the Pap smear are abnormal, in general, care should be provided according to the Guidelines for Management of Women with Abnormal Cervical Cancer Screening Tests by the American Society for Colposcopy and Cervical Pathology (http://www.asccp.org/ConsensusGuidelines/tabid/7436/Default.aspx).
  • HIV-infected adolescent females should be referred for colposcopy if they have any of the following: squamous intraepithelial lesion (SIL), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), or atypical squamous cells—cannot exclude a high grade intraepithelial lesion (ASC-H). For HIV-infected adolescent females with atypical squamous cells of undetermined significance (ASC-US), either immediate referral to colposcopy or repeat cytology in 6-12 months is recommended. If ASC-US or greater is found on repeat cytology, referral to colposcopy is warranted (BIII). Use of HPV testing is not recommended for screening or for triage of HIV-infected women with abnormal cytology results or follow-up after treatment (BIII).
  • Because of the high rate of recurrence after treatment, conservative management of cervical intraepithelial neoplasia-1 (CIN1) and CIN2 with observation is the preferred method for HIV-infected adolescent females (BIII).
  • Because risk of recurrence of CIN and cervical cancer after conventional therapy is increased in HIV-infected females, patients should be carefully followed after treatment with frequent cytologic screening and colposcopic examination according to published guidelines (AII).
  • Genital warts should be treated per the 2010 Centers for Disease Control and Prevention STD treatment guidelines (located at http://www.cdc.gov/std/treatment/2010/)
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials in children with clinical outcomes and/or validated endpoints; I* = One or more randomized trials in adults with clinical outcomes and/or validated laboratory endpoints with accompanying data in children from one or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; II = One or more well-designed, nonrandomized trials or observational cohort studies in children† with long-term outcomes; II* = One or more well-designed, nonrandomized trials or observational studies in adults with long-term clinical outcomes with accompanying data in children from one or more similar nonrandomized trials or cohort studies with clinical outcome data; III = Expert opinion

Studies that include children or children/adolescents, but not studies limited to post-pubertal adolescents

Dosing Recommendations for Prevention and Treatment of Human Papillomavirus (HPV)
Indication First Choice Alternative Comments/Special Issues
Primary Prophylaxis HPV vaccine
N/A
See Figure 2 for detailed vaccine recommendations.
Secondary Prophylaxis N/A N/A N/A
Treatment
  • Podofilox solution/gel (0.5%) applied topically BID for 3 consecutive days a week up to 4 weeks (patient applied). Withhold treatment for 4 days and repeat the cycle weekly up to 4 times (BIII)
  • Imiquimod cream (5%) applied topically at night and washed off in the morning for 3 non-consecutive nights a week for up to 16 weeks (patient applied) (BII)
  • TCA or BCA (80%–90%) applied topically weekly for up to 3 to 6 weeks (provider applied) (BIII)
  • Podophyllin resin (10%–25% suspension in tincture of benzoin) applied topically and washed off several hours later, repeated weekly for 3 to 6 weeks (provider applied) (CIII)
  • Cryotherapy with liquid nitrogen or cryoprobe applied every 1–2 weeks (BIII)
  • Surgical removal either by tangential excision, tangential shave excision, curettage, or electrosurgery
  • Intralesional IFN-α is generally not recommended because of high cost, difficult administration, and potential for systemic side effects (CIII)
  • Cidofovir topical gel (1%) is an experimental therapy studied in HIV-infected adults that is commercially available through compounding pharmacies and has very limited use in children; systemic absorption can occur (CIII).
  • 5-FU/epinephrine gel implant should be offered in only severe recalcitrant cases because of inconvenient routes of administration, frequent office visits, and a high frequency of systemic adverse effects.
Adequate topical anesthetics to the genital area should be given before caustic modalities are applied.

Sexual contact should be limited while solutions or creams are on the skin.

Although sinecatechins (15% ointment) applied TID up to 16 weeks is recommended in immunocompetent individuals, data are insufficient on safety and efficacy in HIV-infected individuals.

cART has not been consistently associated with reduced risk of HPV-related cervical abnormalities in HIV-infected women.

Laryngeal papillomatosis generally requires referral to a pediatric otolaryngologist. Treatment is directed at maintaining the airway, rather than removing all disease. 

For women who have exophytic cervical warts, a biopsy to exclude HSIL must be performed before treatment. 

Liquid nitrogen or TCA/BCA is recommended for vaginal warts. Use of a cryoprobe in the vagina is not recommended.

Cryotherapy with liquid nitrogen or podophyllin resin (10%–25%) is recommended for urethral meatal warts.

Cryotherapy with liquid nitrogen or TCA/BCA or surgical removal is recommended for anal warts.

Abnormal Pap smear cytology should be referred to colposcopy for diagnosis and management.
Key to Acronyms: 5-FU = 5-fluorouracil; BCA = bichloroacetic acid; BID = twice daily; cART = combination antiretroviral therapy; HPV = human papillomavirus; HSIL = high-grade squamous intraepithelial lesion; IFN-α = interferon alfa; TCA = trichloroacetic acid; TID = three times daily

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