Strong evidence is now available that testing for human papillomavirus (HPV) infection is more sensitive than cytology in detecting high grade cervical intraepithelial neoplasia, and some randomised controlled trials showed that HPV testing is able to detect, earlier than cytology, persistent and therefore clinically relevant neoplasia.1 2 However, HPV testing is less specific than cytology.3 The best management of HPV positive women is therefore of major concern.

In one of two linked articles (doi:10.1136/bmj.b2569),4 Castle and colleagues show that the risk of developing high grade cervical intraepithelial neoplasia in the next three to five years is much higher in women with HPV infection that has persisted for at least one year than in those in whom the infection cleared. This suggests that HPV positive women need repeat testing, with differential management of those with or without persistent infection. Randomised trials have shown that if only HPV positive women with cytological abnormalities or persistent infection are referred for colposcopy, the positive predictive value for colposcopy referral is similar to that for cytological screening. …