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  • • Gray or flesh-colored, pedunculated, and moist papules on the penis, urethra, vulva, cervix, anus, or perineal and perianal areas.
  • • One or several grouped lesions may be present, ranging in size from a few millimeters to several centimeters.
  • • Symptoms may include burning, itching, pain, and fullness (urethra, vagina, or anus); however, many patients are asymptomatic.

Human papillomavirus (HPV) is one of the most common sexually transmitted diseases (STDs) and is the cause of genital warts (condylomata acuminata), anogenital dysplasia, and invasive cancer. Oral warts may also occur as a direct consequence of HPV infection during sexual activity. At least 75% of sexually active men and women acquire one or more genital HPV types at some point in their lifetime. The incubation period from HPV infection to condyloma is usually 3–4 months, with a range of 1 month to 2 years, but many infected persons have subclinical disease or have regression of disease before it becomes clinically apparent. HIV-infected patients have a higher prevalence of genital warts than HIV-uninfected patients. These may proliferate further during immune reconstitution following the initiation of antiretroviral therapy.

There are more than 100 different HPV types; 40 of these can cause anogenital lesions. HPV types 6 and 11 are most commonly associated with genital warts; these types have a low risk of malignant transformation. Other types (eg, 16, 18, 31, 33, and 35) have a strong association with cervical and other anogenital cancers. Thus, genital warts lie on one spectrum of a continuum of HPV-associated disease, with warts being one variant of low-grade disease that has little risk of malignant potential. High-grade HPV-associated disease such as cervical intraepithelial neoplasia (CIN) types 2 and 3 are likely the direct precursors to invasive cancer and are the target of screening programs that utilize the Papanicolaou (Pap) test.

Chin-Hong PV, Palefsky JM. Natural history and clinical management of anal human papillomavirus disease in men and women infected with human immunodeficiency virus. Clin Infect Dis 2002;35:1127–1134.  [PubMed: 12384848] (Excellent review of anal HPV disease and HIV infection.)
Conley LJ, Ellerbrock TV, Bush TJ, et al. HIV-1 infection and risk of vulvovaginal and perianal condylomata acuminata and intraepithelial neoplasia: A prospective cohort study. Lancet 2002; 359:108–113.  [PubMed: 11809252] (Prospective study showing that HIV-infected women may be 16 times more likely to develop HPV-related anovaginal disease, including invasive vulvar carcinoma, than HIV-uninfected women.)
Massad LS, Silverberg MJ, Springer G, et al. Effect of antiretroviral therapy on the incidence of genital warts and vulvar neoplasia among women with the human immunodeficiency virus. Am J Obstet Gynecol 2004;190:1241–1248.  [PubMed: 15167825] (Multicenter prospective study showing that warts and vulvar intraepithelial neoplasia are common among women with HIV infection, and highly active antiretroviral therapy decreased their incidence.)

Most anogenital HPV is believed to be acquired via sexual transmission. Following acquisition of infection, HPV infection is established initially in the ...

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