Human papilloma virus

Human papilloma virus testing aims to identify women who may have a cervical abnormality and require further diagnostic testing.

48.1 Background

Cervical cancer is one of the most preventable and curable cancers. Cells in the cervix show changes or ‘abnormalities’ before any progression to cancer, which takes around 15 years. Most low-grade abnormalities regress without treatment. High-grade abnormalities may occur after persistent infection with human papilloma virus (HPV), which is a sexually transmitted infection that generally has no symptoms and resolves within 2 years. In a small number of women, persistent infection with a high-risk type of HPV may eventually lead to cervical cancer AIHW 2012. HPV 16 and 18 are high-risk types that are detected in 70–80% of cases of cervical cancer in Australia AIHW 2012. A program of vaccination against HPV types 16 and 18 (as well as types 6 and 11, which have a lower risk of causing cancer but are associated with 90% of genital warts) was introduced in Australia in 2007 DoH 2013.

48.1.1 Cervical cancer and screening in Australia

• Prevalence of HPV infection: An Australian study (before the introduction of the vaccination program) found that prevalence of HPV types 16 and 18 was similar for Aboriginal (9.4% and 4.1%) and non-Indigenous women (10.5% and 3.8%) (Garland et al 2011). Prevalence of HPV infection is higher among women from developing countries, with regions of high prevalence including Africa (22.1%) and Central America and Mexico (20.4%) (de Sanjose et al 2007). In all world regions, HPV prevalence is highest among women younger than 35 years (de Sanjose et al 2007).
• Other risk factors for cervical cancer: The risk of progression of HPV-related abnormalities to cervical cancer is increased by immunodeficiency (such as that caused by HIV infection), higher number of pregnancies, tobacco smoking, co-infection with other sexually transmitted infections and long-term (>5 years) use of oral contraceptives WHO 2006.
• Cervical cancer incidence and mortality: Incidence of, and mortality from, cervical cancer in Australia have remained at historic lows of 9–10 new cases and 2 deaths per 100,000 women since 2002 AIHW 2012. Incidence does not vary significantly with geographical region but mortality is higher in remote areas AIHW 2012. In 2004–08, the incidence of cervical cancer was 2.8 times higher among Aboriginal and Torres Strait Islander women than among non-Indigenous women AIHW & AACR 2012, with data from 2006–10 showing that mortality was 4.4 times higher AIHW 2012. Women from developing countries have an increased incidence, with the highest incidence (>45 per 100,000 women) found in Central and South America, eastern Africa, South and South-East Asia, and Melanesia WHO 2006.
• Uptake of cervical screening: In 2009–2010, 57% of women in the Australian screening population had Pap smears, with participation highest among women aged 40–54 years AIHW 2012. While cervical screening among women aged 20–24 years is low and decreasing, Australia is one of the few countries that screen this age group AIHW 2012. Participation in screening did not vary significantly by geographical region but was lower in areas of social disadvantage AIHW 2012. Information on participation for Aboriginal and Torres Strait Islander women is not available, as Indigenous status of participants is not collected, although there is evidence that this population group is under-screened Coory et al 2002, Binns & Condon 2006.

48.2 Testing for human papilloma virus 

Current recommendations in Australia are that women be tested for HPV every 5 years. 

National Cervical Screening Program recommendations

Who

All women who have ever been sexually active, including women who have received HPV vaccination.

What

Human papilloma virus testing of cervical samples and liquid-based cytology testing on samples testing positive.

When

Starting from the age of 25 years, or 1–2 years after first sexual intercourse, whichever is later.

How often

Every 5 years if human papilloma is not detected.

48.2.1 Management of cervical abnormalities

There are few studies detailing the progression of low-grade abnormalities to cancer during pregnancy but this appears to be extremely rare NHMRC 2005. The NHMRC recommends investigation of abnormalities during pregnancy as follows NHMRC 2005:

• in general, women with a low-grade abnormality should have a repeat smear in 12 months
• women with high-grade abnormalities should be referred to a colposcopist experienced in assessing the pregnant cervix.

48.3 Practice summary: cervical abnormalities

When

Early antenatal visit, if the woman has not had a cervical screen in the recommended time period.

Who

• Midwife
• GP
• obstetrician
• Aboriginal and Torres Strait Islander Health Practitioner
• Aboriginal and Torres Strait Islander Health Worker
• multicultural health worker
• sexual health worker
• women’s health provider.

What

• Discuss the reasons for HPV testing
  Explain that 5-yearly tests for HPV are recommended for sexually active women to detect human papilloma virus infection, as persistent infection can cause cervical abnormalities.
• Provide advice to women with a positive result
  Explain that the test is not diagnostic.
• Take a holistic approach
  Provide advice to assist women in accessing services (eg pathology services that bulk bill). Explain that inclusion on the National Cancer Screening Register is confidential and automatic (unless a woman requests otherwise) and that the registries send reminders to women who are overdue for testing.
• Document results and referrals
  If a woman has a cervical screening test, tell her the results and note them in her antenatal record. Also document inclusion on the national registry and any follow-up required.

48.4 Resources

• NHMRC (2005) Screening to Prevent Cervical Cancer: Guidelines for the Management of Asymptomatic Women with Screen-detected Abnormalities. Canberra: National Health and Medical Research Council.
• WHO (2014) Comprehensive Cervical Cancer Control: A Guide to Essential Practice. Geneva: World Health Organization.