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Table of Contents
- What Is HPV?
- Genital Warts
- Cervical Dysplasia and Cervical Cancer
- Anal Dysplasia and Anal Cancer
- Preventing HPV
- Taking Care of Yourself
What Is HPV?
Human papillomavirus (HPV) is the name of a large group of viruses. Certain types of HPV can cause warts on the hands, feet, mouth, or throat. About 30 to 40 types can cause infections in the genital area (the vulva, vagina, penis, buttocks, scrotum, and anus).
Genital HPV is a very common sexually transmitted infection or disease (STI or STD) worldwide. The World Health Organization (WHO) estimated HPV infection was responsible for more than half a million cases of cervical cancer in 2019, and most deaths from this condition occurred in resource-limited areas of the world.
Genital HPV types are often grouped as "low risk" or "high risk." Low-risk types can cause genital warts. High-risk types can cause cervical cancer or cancer of the vulva, vagina, anus, and penis. The types of HPV that can cause genital warts are not the same as the types that can cause cancer. However, if you have warts, you may have also been exposed to the types of HPV that can cause cancer.
Genital HPV is spread easily through skin-to-skin contact during vaginal or anal sex with someone who has the infection. HPV can be spread between sexual partners without a penis in a partner's vagina, anus or throat. It can also be spread between women through skin-to-skin contact. Condoms and other latex barriers do not totally prevent transmission. Most people with HPV do not know they have it because they do not develop symptoms, yet they can still pass the virus on to someone else.
It is very important that people living with HIV who have a cervix get routine cervical screening tests and follow up as needed to find problems before cancer develops.
Although most sexually active people will have HPV at some point, nine times out of ten, the body's immune system clears HPV infection naturally (gets rid of the infection without treatment) within two years. Because HIV weakens the immune system, people living with HIV are more likely than HIV-negative people to have an HPV infection that continues (persistent infection). One study found HPV in more than three out of four women living with HIV. Women living with HIV who have HPV are also more likely to have:
- Difficulty clearing the infection naturally
- HPV infections that were once under control and come back again
- HPV that responds poorly to standard treatment; multiple therapies using different methods may be needed
- Several types or strains of HPV at once
- Infection with the "high-risk" HPV types that can cause cancer
- Greater vulnerability to developing cervical and anal cancer when living with the "high-risk" types
If you have sex, it is important to be checked regularly by your healthcare provider for signs of HPV such as genital warts, cervical cancer, and anal cancer. For information on vaccines and routine screenings for HPV, see the section on Preventing HPV below.
Genital Warts
Certain types of HPV can cause warts on the vulva (including the labia, or "lips"), in or around the vagina or anus, or on the penis, scrotum, groin, or thigh. Warts can appear anywhere from a few weeks to a few months after you have been exposed to HPV. They can even appear years after exposure.
Symptoms:
- Flesh-colored, pinkish, or white warts that appear as small bumps or groups of bumps. They can be raised or flat, different sizes, and are sometimes shaped like cauliflower.
Diagnosis:
- Healthcare providers can usually identify genital warts by looking at them
- Sometimes a biopsy is done (a sample of the suspected wart is cut off and examined under a microscope)
- Some healthcare providers may use a vinegar solution to help identify flat warts with the naked eye; however, this test may sometimes wrongly identify normal skin as a wart
Treatment:
There is no cure for HPV, but if genital warts do not go away on their own, they can be removed by your healthcare provider.
- The following treatments must be done in a healthcare provider's office:
- TCA (trichloracetic acid): Applying a chemical to the surface of the wart
- Cryotherapy: Freezing off the wart with liquid nitrogen
- Electrocautery: Burning off the wart with an electrical current
- Laser therapy: Using an intense light to destroy the wart
- Excision: Cutting out the wart
- Some treatments can be done at home with prescription creams: Aldara or Beselna (imiquimod), Condylox (podofilox or podophyllotoxin), and Veregen (sinecatechins, or green tea extracts). Because Aldara and Beselna act on the immune system, it is important to talk with your healthcare provider about the best prescription wart treatment for you if you are living with HIV.
- Do not use over-the-counter wart removal products to treat genital warts
- Some wart treatments should not be used by pregnant people or people who are breast/chestfeeding
- Warts can reappear after successful treatment
If left untreated, genital warts may go away, remain unchanged, or increase in size or number. Some people decide not to have treatment right away to see if the warts will go away on their own. When considering treatment options, you and your healthcare provider may take into account the size, location and number of warts, changes in the warts, your preference, and the side effects of treatment.
Many people living with HIV, especially those with low CD4 cell counts, may not be able to get rid of genital warts using standard treatments. Several different treatments may be needed. One of the best ways for people living with HIV to strengthen their immune system and help get rid of genital warts is to take HIV drugs. If you are already taking HIV drugs, it is important that you take them exactly as directed so that they can increase your CD4 count and help your body fight off HPV.
For pictures of different sexually transmitted infections, including genital warts caused by HPV, please click here (note: some of these images are graphic).
Cervical Dysplasia and Cervical Cancer
Certain types of HPV can cause abnormal cells to form. This is called dysplasia. The main place dysplasia occurs is on the cervix (entrance to the womb). Other less common areas are the vagina, vulva, and anus. Dysplasia is not cancer but can develop into cancer if it is left untreated. For this reason, cells with dysplasia are sometimes referred to as pre-cancerous cells.
Screening for dysplasia and cervical cancer is essential to find and treat early pre-cancerous changes and to prevent cervical cancer. Traditionally, the Papanicolaou test (Pap test or Pap smear) has been done. This test uses a small brush to collect a few cells to check for abnormal cells in the cervix.
Because Pap tests require laboratories and people skilled in reading the tests, resource-limited countries offer different tests to screen for dysplasia and cervical cancer. One method is called visual inspection with acetic acid, or VIA. When using VIA, healthcare providers swab acetic acid (also known as vinegar) on the cervix and look directly at it to see if any areas need treatment. Other countries use HPV tests, which test samples taken from your cervix for the presence of HPV's DNA (the virus' genetic material).
Screening for dysplasia and cervical cancer is essential to find and treat early pre-cancerous changes and to prevent cervical cancer.
Cervical cancer usually takes years to develop, but it does not have symptoms until it is quite advanced. This is why getting screened on a regular basis is important; screening can catch potential problems before they get worse. It is especially important for people with a cervix who are living with HIV to have cervical screening tests. This is because people living with HIV are more likely to have abnormal cervical screening tests than people who are not living with HIV.
Cervical cancer can be life threatening. It is one of the few AIDS-defining conditions specific to women and other people with a cervix. Fortunately, it can be prevented through early diagnosis and treatment.
Symptoms:
- Many people do not experience symptoms
- In very advanced stages, some may experience abdominal pain, vaginal discharge, bleeding after having vaginal sex, and bleeding between periods
Screening and diagnosis:
In the US, according to the Guidelines for the Treatment and Management of Opportunistic Infections in Adults and Adolescents with HIV:
- Women living with HIV between the ages of 21 and 29 should have a complete gynecological examination, including a cervical screening test and a pelvic exam, when they are first diagnosed, and then another every year. Once they have three normal Pap tests, they can be screened every three years. HPV testing is not recommended for women under the age of 30.
- Women 30 and over should have a complete gynecological exam and Pap test at HIV diagnosis and every year thereafter. After three normal tests, they can be screened every three years.
- Another option is an initial complete exam, Pap and HPV test regardless of age. If all are normal then screening can be repeated every three years. If the HPV test is positive, another Pap with repeat testing is performed in a year. This is the most common option in the US.
- Pregnant women living with HIV should have a cervical cancer screening test when they first seek prenatal care
- Women who were born with HIV (perinatally acquired) are more likely to have advanced disease; therefore, cervical screening should start before they are 21 years old if they are sexually active
- An abnormal cervical screening test can indicate inflammation, infection, dysplasia, or cancer
- If you have an abnormal cervical screening test, you will need close follow-up and possibly a colposcopy (an exam of your cervix using a magnifier to look at the tissue more closely) and a biopsy (a small amount of tissue is removed so it can be checked under a microscope for signs of cancer)
- An HPV test can be used along with the cervical screening test to look for high-risk HPV types that may lead to cancerous and pre-cancerous conditions. Speak with your healthcare provider to see if your cervical screening test includes an HPV test.
From the World Health Organization (WHO):
- Women living with HIV should be screened for cervical cancer, regardless of age
- Women living with HIV should be screened for cervical cancer regularly (e.g., once a year)
- If you have a VIA or HPV test that shows an abnormality, you may need treatment (see below); which screening tests and treatments are available will depend on where you live
Many countries have screening and diagnosis guidelines that differ from the WHO and US guidelines listed above. Please check with your country or region to see what the standard of care is in your area.
Treatment for cervical dysplasia:
If you have dysplasia, discuss treatment choices with your healthcare provider. Most treatments focus on destroying the abnormal cells so that they do not become cancer.
- Laser therapy: Using an intense light to destroy the cells
- Cold-knife cone biopsy (conization): Cutting the cells out (an operation)
- LEEP: Loop Electrosurgical Excision Procedure, which uses a thin electrified wire loop to cut out the cells
- Cryotherapy: Freezing the cells with liquid nitrogen
- In cases of mild dysplasia, your healthcare provider may just monitor the cervix by colposcopy, repeat cervical screening tests, and/or an HPV test
Cervical dysplasia is more common in women living with HIV who have advanced HIV disease and low CD4 cell counts. Cervical dysplasia is often more serious and difficult to treat in women living with HIV than in HIV-negative women.
Treatment of cervical cancer:
Cervical cancer can be treated better when it is diagnosed and treated early, so regular cervical screening tests are extremely important. Treatment depends on the type of cervical cancer and how far it has spread. Often, more than one kind of treatment is used. Treatments include:
- Surgery: Cancer tissue is cut out in an operation
- Chemotherapy: Drugs (pills and/or intravenous medications) are used to shrink or kill the cancer
- Radiation: High-energy rays (similar to X-rays) are used to kill the cancer cells
For more information, see our fact sheet on Cancers.
Anal Dysplasia and Anal Cancer
Certain types or strains of HPV may cause dysplasia and cancer in the anus (butt). Although the risk of developing dysplasia is higher among men who have sex with men, women and others are also at risk, especially those living with HIV or who have had receptive anal sex (one partner puts their penis into another partner's anus).
Symptoms:
- Many do not experience symptoms
- Anal or rectal bleeding, irritation, itching, or burning
- In very advanced stages, there may be abscesses, lumps, ulcers, and anal discharge
Screening and diagnosis:
- Careful physical examination by a healthcare provider may be the best way to find anal cancers
- An abnormal anal Pap test may be a sign of dysplasia or cancer
- Your provider may also perform a digital rectal exam (DRE), in which they slide a lubricated, gloved finger through your anus and into your rectum to feel for abnormal masses
- If you have symptoms, you may need an anoscopy (an exam of the anus using a magnifier to look at the tissue more closely) and a biopsy (tissues are removed so they can be checked under a microscope for signs of cancer)
- It is a good idea to discuss your vulnerability to anal cancer with your healthcare provider and decide together with them whether screening is right for you
Treatment for anal dysplasia:
If you have dysplasia, discuss treatment choices with your healthcare provider. Most treatments focus on destroying the abnormal cells so that they do not become cancer.
- Infrared coagulation: Using infrared light to cut off the blood supply to the cells and thereby kill them
- Electrocautery: Burning off the cells with an electrical current
- Laser therapy: Using an intense light to destroy the cells
- Surgery: Using a surgical knife to cut out the cells
- Cryotherapy: Freezing the cells with liquid nitrogen
Anal dysplasia is more common in women living with HIV than in HIV-negative women. This is especially true for women with advanced HIV disease and low CD4 cell counts. Anal dysplasia is often more serious and difficult to treat in women living with HIV than in HIV-negative women. For people living with HIV, taking HIV drugs can strengthen the immune system and help anal dysplasia become less severe. If you are already taking HIV drugs, it is important that you take them exactly as directed so that they can increase your CD4 count and help your body fight the HPV that can cause anal cancer.
Treatment of anal cancer:
Anal cancer can be treated better when it is diagnosed and treated early, so regular exams are helpful. Treatment depends on the type of anal cancer and how far it has spread. Often, more than one kind of treatment is used. Treatments include:
- Surgery: Cancer tissue is cut out in an operation
- Chemotherapy: Drugs (pills and/or intravenous medications) are used to shrink or kill the cancer
- Radiation: High-energy rays (similar to X-rays) are used to kill the cancer cells
For more information, see our fact sheet on Cancers.
Preventing HPV
Vaccines
The vaccines protect against types of HPV that cause the majority of cervical cancers and genital warts.
There are currently three HPV vaccines: Gardasil (also known as Silgard), Gardasil-9, and Cervarix. All three have been approved by the US Food and Drug Administration (FDA), Health Canada, and the European Medicines Agency (EMA). Demonstration projects now bring HPV vaccines to girls and women in low-income countries as well.
In the US, Gardasil and Cervarix are no longer distributed. Gardasil-9, which covers the same four HPV types as Gardasil along with five additional HPV types, is the only HPV vaccine available in the US. It has been approved for girls and boys ages 9 to 45.
The vaccines protect against types of HPV that cause the majority of cervical cancers and genital warts. Recent studies have shown that these vaccines can also provide protection against HPV-related vaginal cancers, vulvar cancers, and anal cancer in women. The vaccines do not protect against less common HPV types. Therefore, healthcare providers still recommend regular screenings to look for signs of cancer.
It is best if young people get all doses of the vaccine before their first sexual contact. This helps them develop an immune response before they are exposed to HPV. People who are infected with some types of HPV may still benefit from the vaccine's effects against other types of HPV. The US Centers for Disease Control and Prevention (CDC) recommends HPV vaccines for both girls and boys. The HPV vaccine is routinely given at ages 11 or 12.
In Canada, the National Advisory Committee on Immunization (NACI) recommends Gardasil vaccination for girls/women ages nine through 45 and boys/men ages nine through 26, or vaccination with Cervarix for girls/women ages nine through 45. In the UK, vaccination with Gardasil is offered to girls ages 12 and 13 through the National Health Service.
Pregnant people should not receive the vaccine. However, it is safe to get the vaccine while breast/chestfeeding. Speak to your healthcare provider about the HPV vaccine to see if it is right for you. In the US, there are payment assistance programs for people who cannot afford the HPV vaccines; see the Additional Resources section of this fact sheet for contact information.
Based on recent studies showing that HPV vaccines are very good at getting the body to produce a strong immune response, some countries have reduced the number of doses needed. Girls and boys ages nine to 13 have a stronger response to the vaccine than older adolescents. Therefore, the European Medicines Agency recently approved a two-dose vaccination with Cervarix or Gardasil for pre-adolescent children. In October 2016, the CDC recommended that girls and boys under 15 years of age receive two doses of the HPV vaccine, while those who begin the vaccine series on or after their 15th birthday continue to receive three doses.
To reduce the total number of injections, future HPV vaccine development includes the possibility of adding the HPV vaccine to another existing vaccine (e.g., combining it with the measles vaccine in one shot).
Routine Screenings
Regular pelvic and anal exams and cervical screening tests are very important. While they cannot prevent HPV-related problems, they can help catch warts and dysplasia (abnormal or pre-cancerous cells) before they get worse and cause greater problems.
Although women living with HIV are at greater risk for developing cervical cancer, nearly one in four women living with HIV in the US did not have a cervical screening as recommended. It is very important that people living with HIV who have a cervix get routine cervical screening tests and follow up as needed to find problems before cancer develops. Follow up involves seeing a gynecologist who will look closely at cervical cells with a microscope. This helps them find abnormal cells that might be pre-cancerous. Prevention is always better – healthier, less painful, and less costly – than treatment.
Condoms
Even though condoms do not fully protect against HPV, when used correctly they can help reduce the chances that HPV will be transmitted.
Not Smoking
Smoking has been shown to increase the chance of developing several types of cancer, including cervical and anal cancers. If you smoke, it is a good idea to try and quit. Talk with your healthcare provider about stopping smoking – there are many tools to help you quit. You can also find lots of information and support online.
Taking Care of Yourself
HPV can be very serious for people living with HIV. Since often there are no symptoms, getting regular exams from your healthcare provider is the best way to be sure that any problems are found and treated early.