HPV – human papillomavirus

Almost everyone who has sex becomes infected with human papillomavirus at some point. In nine out of ten cases the infection has gone by itself within two years, without anything having happened. Out of the remainder arises what the whole of cervical screening is directed against. This page explains what HPV is, what a positive test means, what the vaccination achieves and what is paid for in Austria and when.

What human papillomaviruses are

HPV is not a single virus but a family of over two hundred types. Around forty of them affect the mucous membranes of the genital area. They are transmitted by skin and mucous membrane contact, not through blood or body fluids – which is why a condom lowers the risk but does not remove it: it does not cover everything that comes into contact.

In practice the types are divided into two groups:

• Low-risk types, above all HPV 6 and 11. They cause genital warts (condylomas) – a nuisance, contagious, but not dangerous. No cancer arises from them.
• High-risk types, above all HPV 16 and 18, along with 31, 33, 45, 52 and 58. They can trigger cell changes from which a carcinoma develops over years. HPV 16 and 18 alone are responsible for around 70 per cent of all cervical cancers.

Practically every cervical cancer goes back to a persistent infection with a high-risk type. That is unusual: for hardly any other cancer can a single necessary cause be named so clearly – and precisely for that reason this is the only cancer that can be almost completely prevented by a vaccination.

How common infection is

About eight in ten sexually active people become infected at least once in their lives. Most notice nothing. The immune system eliminates the virus in around 90 per cent of cases within one to two years.

From that follows a sentence that brings much relief in consultations: a positive HPV test is not a diagnosis but a snapshot. It says that the virus is detectable now – not that it will stay, and certainly not that cancer is present.

It also says nothing about when the infection took place. HPV can persist unnoticed for years and only become detectable later. A positive result in a long relationship is therefore no proof of infidelity – a point that deserves raising more often than it is.

The path from infection to disease

What becomes dangerous is not the infection but its persistence. If a high-risk type remains for years, it can change the cells of the cervix so that precursors arise. These are classified by their extent:

Between a persistent infection and an invasive carcinoma lie ten to fifteen years on average. This long span is the reason screening works so well: there are plenty of opportunities to find a precursor while it is still easy to treat.

The commonest reason a cervical cancer is missed is therefore not a smear read wrongly, but a smear never taken.

What is examined in Austria

Since 2024 the HPV test has counted in Austria as the primary screening method for women from 30. As a recommendation there is good reason for that: the HPV test identifies a risk earlier and more reliably, because it looks for the cause rather than its consequences. Between this recommendation and what public insurance pays for, however, lies a difference that has to be explained at this practice almost daily: as a routine screening test the HPV test is not covered. It is paid for where there is an indication – as a rule an abnormal smear.

Why not in every woman? Because a positive HPV test without any cell change entails nothing that could be treated. It produces a conversation about a virus for which there is no remedy, and worry with no consequence – particularly often in young women, because HPV infections are common there and almost always heal by themselves. The smear, by contrast, shows whether cells have actually changed. That is why it comes first at this practice, at every age; the HPV test follows when the result calls for it – and is then covered by insurance.

What is due at your age and what insurance covers is shown by the screening planner.

How the smear and the HPV test are done

Both are obtained in the same way and differ only in what the laboratory does with the sample. After a speculum is inserted, the cervix is brought into view and a small brush is swept across it. That takes a few seconds. Most women feel a brief pressure, some a slight cramping sensation; pain in the proper sense is rare. Light spotting afterwards is normal and harmless.

The smear is assessed under the microscope: a cytologist looks at the cells and describes whether and how far they are changed. The HPV test, by contrast, looks in the same material for the genetic material of the high-risk types. It does not answer the question “are cells changed?” but “is the cause present that could change them?”.

From that follows the decisive practical difference. A negative smear says: everything is normal today. A negative HPV test says something in addition about the coming years, because the cause is absent – it makes a cancer in the years ahead less likely. From the age of 30 the HPV test is therefore an alternative route to early detection, and it picks up precancerous changes earlier and more reliably. It does not replace the smear, though: some precancerous changes and cancers are HPV negative and show only in the cells. That is why the smear is taken here at every check-up. What is covered in Austria is the annual smear, and the HPV test for certain indications; on request it can be done at any time as a private service.

For a usable result the smear should not be taken during bleeding. In the two days beforehand no pessaries, creams or douches should be used; intercourse on the previous day is usually avoided. If you are unsure whether the timing suits, settle it when making the appointment – an unusable smear means a second visit.

Genital warts

Genital warts, medically condylomata acuminata, are the commonest visible consequence of an HPV infection and almost always go back to types 6 and 11. They appear as soft, skin-coloured to reddish lumps in the genital or anal area, singly or in groups, and grow slowly. They usually do not hurt but can itch, burn or bleed.

They are contagious, and they are harmless in the sense that no cancer arises from them – the types that cause them belong to the low-risk group. That does not change the fact that they are a considerable burden for many people affected. It is precisely this gap between medical harmlessness and emotional burden that deserves saying out loud.

Treatment depends on number, size and location: a cream for self-application over some weeks, freezing, or removal with laser or electrical loop. None of these methods removes the virus, they only remove the warts; recurrences in the first months are therefore common, and become rarer with time as the immune system catches up. Anyone who is vaccinated as a rule does not get them in the first place.

A positive HPV test – what now?

First: do not be alarmed. About one woman in ten over 30 has a positive high-risk result, and the great majority of them will never develop a cell change.

What happens next depends on the cell picture:

• HPV positive, cells normal: a check after twelve months. If the virus has gone by then, things continue at the normal rhythm.
• HPV positive, cells abnormal: colposcopy – an examination of the cervix with a strong magnifying lens, in which abnormal areas are made visible with acetic acid and iodine solution and, if needed, a small tissue sample is taken. It is uncomfortable but brief.
• HPV 16 or 18 detected: these two types carry the highest risk. Here a colposcopy usually follows directly, irrespective of the cell picture.

If a higher-grade precursor is confirmed, the usual treatment is conisation: a cone-shaped piece of tissue is removed from the cervix, usually with an electrical loop, as a day case under a short anaesthetic. As a rule it is curative. For later pregnancies it is worth knowing that a large or repeated conisation slightly raises the risk of premature birth – one more reason not to remove more tissue than necessary, and a reason why in young women with CIN 2 monitoring often comes before surgery.

The vaccination

In Austria the nine-valent vaccine Gardasil 9 is used. It protects against types 6, 11, 16, 18, 31, 33, 45, 52 and 58 – so against the causes of around 90 per cent of cervical cancers and at the same time against the two types that cause genital warts.

How effective it is: in countries with high vaccination coverage the data now show what the vaccination achieves. A Swedish study of over 1.6 million women showed that with vaccination before the age of 17 the frequency of invasive cervical cancer fell by around 88 per cent. That is not a model but counted cases.

When it works best: before first intercourse, because there has then been no encounter with the types it contains. It remains useful afterwards, however – hardly anyone has met all nine types, and it continues to protect against the rest.

How many doses: up to the 15th birthday two doses six to twelve months apart are enough. From 15, three doses are provided for.

What it costs in Austria: the free vaccination programme covers it from the completed 9th to the completed 21st year of life – for girls and boys alike. It stays recommended up to the completed 30th year, though self-funded from 21 on, and it remains possible beyond that at any time, if you want it. The conditions of this programme have been extended and prolonged several times; the vaccination service or this practice can tell you what currently applies.

Why boys are vaccinated too: not only to protect girls. HPV also causes penile, anal and throat cancers, and the number of HPV-related throat cancers in men has been rising for years. The benefit is direct.

How safe the vaccination is

Hardly any vaccine has been observed so thoroughly. Well over 500 million doses have been given worldwide, and the safety data are correspondingly extensive. The commonest side effects are local and brief: pain, redness and swelling at the injection site, less often headache, tiredness or a slight fever for a day or two.

Two claims persist stubbornly and both have been investigated. A connection with chronic fatigue syndrome or with autoimmune disease could not be found in large registry studies of millions of vaccinated girls – the frequency of illness was the same in vaccinated and unvaccinated. And an effect on later fertility is neither biologically plausible nor visible in the data; if anything the opposite applies, because a conisation avoided preserves the function of the cervix.

What does occur are circulatory reactions in adolescents immediately after the injection – dizziness up to a brief faint. That is not a reaction to the vaccine but to the situation, and the reason for staying seated for a quarter of an hour afterwards.

Vaccination coverage in Austria is well below that of the countries in which the fall in cancers is already measurable. That is not a medical but an organisational problem: the vaccination is free, it is effective, and it is still often not taken up, because it is not embedded in any routine procedure. Anyone who raises the question in a consultation gets a clear answer here.

What the vaccination does not replace

The screening examination. The vaccine covers nine types, not all cancer-causing ones – around ten per cent of carcinomas go back to others. Vaccinated women therefore continue to take part in screening, only with a considerably lower probability of an abnormal result.

Nor does it cure an existing infection. Anyone already HPV positive is not freed of it by the vaccination – but it does protect against the other types it contains, which makes it worthwhile even then.

HPV and pregnancy

An HPV infection does not endanger the pregnancy. The baby is practically never infected; the rare transmission during birth leads to problems only in exceptional cases and is no reason for a caesarean section.

Genital warts can grow faster in pregnancy, because the immune system is altered. Treatment is cautious and uses different agents from usual; after the birth they often regress by themselves.

The vaccination is not given in pregnancy – not because harm is known, but because there is no licence for it. If it has been given inadvertently, that is no cause for concern; the course started is continued after the birth. Breastfeeding is no obstacle.

If you are planning a pregnancy, complete the vaccination beforehand – and have your rubella protection checked as well. What else needs settling before a pregnancy is in the screening planner.

What you can do yourself

• Do not smoke. Smoking is the most important modifiable factor in whether an HPV infection persists or heals. The toxins weaken the local immune defence at the cervix.
• Go for screening. Annually, whether or not you have symptoms – cell changes do not hurt and usually do not bleed.
• Get vaccinated – free up to the 21st birthday, and still possible after that at your own expense.
• Use condoms with changing partners. They lower the risk considerably, even though they do not remove it.

Where to go from here

Whether an HPV test, a smear or both is due for you depends on your age and your last result. For vaccination advice, for the assessment of an abnormal result or for the annual check-up: make an appointment. What is provided for at your age is shown by the screening planner.

If you are bringing a report you cannot interpret: bring it in the original, not as a memory of what was said. The abbreviations on a cytology report cannot be decoded by a layperson, and the differences between them decide whether monitoring or treatment follows. An appointment in which the report is gone through together as a rule saves more worry than it costs.