Treatment of cutaneous and anogenital warts is directed on the alleviation of signs and symptoms with traditional treatment modalities focusing on the destruction of infected tissue.  First-line treatments for warts include cryotherapy or keratolytics such as topical salicylic acid-based preparations, either separately or in combination. (53) Refractory warts may require referral for off-label therapies, such as imiquimod, cantharidin, podophyllin, podophyllotoxin, laser or surgery. Intralesional and intramuscular HPV vaccination has also demonstrated high complete clearance rates for cutaneous warts (82% and 63%, respectively) in a population without concomitant HIV. (62)  

Despite the fact that patients with HIV infection tend to have larger or more numerous warts which may be more refractory to standard treatments, data does not support altered approaches to treatment for PLWHIV. (54) Topical imiquimod has been shown to be safe and effective for anogenital warts in men living with HIV, with a randomised trial showing higher rates of >50% clinical improvement compared to placebo (38% versus 14%). (63) Best outcomes have been with application three times a week for 6-10 weeks until visible inflammation occurs and the warts disappear. Side effects can be controlled by decreasing the frequency of application. Recent evidence suggests topical cidofovir to be effective in treating anogenital warts and Bowenoid papulosis in patients with HIV infection. However, its cost limits its widespread use. (64, 65) 

In immunocompetent populations, vaccines against high-risk HPV subtypes have been shown to reduce the incidence of associated anal and cervical cancer. (66, 67) These vaccines are safe and immunogenic in populations living with HIV, (68) however evidence for their efficacy in reducing HPV-associated malignancies in this group is limited due to their exclusion from clinical trials. The management, screening and monitoring of anogenital HSIL are described in section Oncological conditions.