Follow-Up to High-Resolution Anoscopy After Abnormal Anal Cytology in People Living with HIV

A Sequential Mixed-Methods Study of Factors Associated with Low High-Resolution Anoscopy Completion in Transgender Women with Abnormal Anal Cytology

In a cohort of transgender women (TGW) with abnormal anal cytology (AAC) in Washington, DC, we determined the rates of and factors associated with completion of high-resolution anoscopy (HRA). This mixed-methods study used a sequential study design. In an academic-community clinic, we recruited TGW who provided blood samples, anal swabs for anal cytology, and completed surveys. For the quantitative phase of this study, we used χ2 test to compare factors associated with HRA completion among TGW with AAC. From that cohort, we used purposive sampling to recruit 16 TGW for qualitative interviews, based on their HRA completion status. We used thematic analysis to analyze the qualitative data. Of 75 TGW, 36 (48%) had AAC, 32 (43%) were referred to HRA, and 15 (20%) completed HRA. HRA completion was associated with being employed (75% vs. 25%; p = 0.01) in the quantitative phase, and low socioeconomic status (SES) was considered a barrier to completing HRA in the qualitative phase. HRA completion was associated with suppressed HIV (67% vs. 18%; p = 0.01) in the quantitative phase. In the qualitative phase, trans-affirming care, receptive anal sex, and engaging in sex work were identified as motivators to completing HRA. In a population of TGW, we found high rates of AAC and low rates of HRA completion. Interventions targeting this gap should address barriers associated with low SES and HIV viremia in TGW. Trans-affirming care and the impact on anal sexual practices should be used as motivators to engage TGW in anal cancer screening.

Anal Cancer Screening: 10-Year Experience of a Specialized Outpatient Clinic

In 2012, the Department of Visceral Surgery of the Lausanne University Hospital CHUV implemented a dedicated high-resolution anoscopy (HRA) outpatient clinic for surveillance and follow-up purposes. This 10-year longitudinal study analyzed 537 patients (2214 visits) using a structured screening protocol. Dysplastic lesions were detected in 49% of patients, predominantly low-grade squamous intraepithelial lesions (LSILs, 74%). Among LSIL cases, 6% progressed to high-grade squamous intraepithelial lesions (HSILs) within 24 months, reaching 25% cumulative progression at 36 months. Of HSIL patients, 3% developed carcinoma in situ after 48 months. Notably, no invasive carcinoma was observed during the follow-up. Four patients diagnosed with squamous cell carcinoma at initial screening were treated with chemoradiotherapy, and one required salvage surgery. Independent risk factors for the presence of higher-stage precancerous lesions (≥HSILs) were the presence of high-risk HPV genotypes (OR 14.5, 95% CI 5-42.2, p < 0.001), detectable HIV viral load (OR 5.4, 95% CI 1.8-16.7, p = 0.003), and symptoms at the first screening visit (OR 3.2, 95% CI 1.1-9.9, p = 0.04). HIV-positive status was associated with a trend towards an increased risk of progression (OR 2.79, p = 0.073). These findings highlight the importance of systematic follow-up and early intervention in high-risk populations to prevent anal cancer progression.

Identifying Motivators, Facilitators, and Barriers to Engagement and Retention in Anal Cancer Screening Among Men and Women with HIV in One Ryan White HIV/AIDS Clinic

Anal squamous cell carcinoma disproportionally affects people with HIV (PWH); however, engagement in anal cancer screening is low in many settings. This study was conducted to assess knowledge and perceptions of anal cancer screening to identify factors in the engagement and retention in prevention services among PWH. Semistructured interviews were conducted among adult PWH eligible for anal cancer screening in our Ryan White HIV/AIDS Program clinic. Descriptive statistics were tabulated; thematic analyses were performed to identify emerging motivators, facilitators, and barriers. Among 26 PWH, 9 had not been screened, 8 had undergone Papanicolaou (Pap) testing alone, and 9 had undergone anoscopy. The median age of the cohort was 55.2 years; 54% identified as men who have sex with men, and 54% identified as Black. In the unscreened cohort, participants were motivated by investing in their health and positive attitudes toward cancer prevention however were deterred by a lack of referral and low awareness about screening. Among those who had Pap testing, trust in healthcare providers and abnormal testing results were motivators to engagement, whereas lack of perceived risk of anal cancer and worry about pain of an anoscopy were prominent barriers. Among those who had anoscopy, perceived risk, positive experience with the procedure, and use of anxiolytics prior to anoscopy were motivators, whereas anxiety around a new cancer diagnosis and negative experience with anoscopy were barriers. Clinics seeking to build or strengthen their anal cancer screening programs can address the barriers described in this study to promote access to anal cancer screening among PWH.

To Improve Motivational Barriers to Retention in High Resolution Anoscopy, Patients and Providers Recommend Social and Environmental Changes: A Sequential Explanatory Mixed-Methods Pilot Study in a Federally Qualified Health Center

Loss to follow-up (LTFU) in high-resolution anoscopy (HRA) programs jeopardizes the procedure's potential to help prevent anal cancer. We explored quality improvement factors to understand how to address this LTFU. Using the transtheoretical COM-B Model (Capability, Opportunity, Motivation, and Behavior) and a sequential explanatory mixed-methods design, we surveyed and interviewed 13 patients who remained engaged in HIV care but who delayed their HRA monitoring or treatment visits in the same community clinic, and 6 HRA clinicians and medical assistants. Analyses involved descriptive statistics and rapid qualitative analysis. Patients were racially, ethnically, and economically representative of the LTFU population, and were generally experienced with HRA (Mean HRA visits = 4.6, SD = 2.8, mdn = 3). Providers were experienced clinicians and medical assistants (Mean years providing HRA = 6.0, SD = 2.2). Analyses revealed two primary, related barriers: (A) motivational barriers such as physical pain, discomfort, embarrassment, and anxiety; which were largely borne from (B) opportunity barriers such as difficulties with scheduling, inconsistent after-care (particularly for pain and discomfort), anxiety-inducing exam rooms and equipment, and internalized and anticipated stigma. Capability barriers, such as limited health literacy about HRA, were less common and, like motivational barriers, linked to opportunity barriers. Participants recommended potential facilitators, including easier scheduling, standardization of pain management and after-care services, and examination room modifications to reduce anxiety. To retain HRA patients in community settings, interventions should address social and physical opportunity barriers that strongly determine motivational and capability barriers. Improving convenience, standardizing pain management, and introducing stigma interventions specific to HRA, could alleviate both motivational and capability barriers.

Prevalence of anal cytology screening among persons with HIV and lack of access to high-resolution anoscopy at HIV care facilities

BACKGROUND

People with HIV at highest risk of anal cancer include gay, bisexual, and other men who have sex with men and transgender women aged 35 years or older as well as other people with HIV aged 45 years or older. Identifying and treating precancerous lesions can reduce anal cancer incidence in these groups. We assessed the prevalence of anal cytology and access to high-resolution anoscopy among people with HIV overall and in those individuals at highest risk.

METHODS

Data were obtained from the Centers for Disease Control and Prevention's Medical Monitoring Project, a population-based survey of people with HIV aged 18 years and older, and a supplemental Medical Monitoring Project facility survey. We report weighted percentages of people with HIV receiving anal cytology during the past 12 months, access to high-resolution anoscopy, and characteristics of HIV care facilities by availability of high-resolution anoscopy.

RESULTS

Overall, 4.8% (95% confidence interval [CI] = 3.4% to 6.1%) of people with HIV had undergone anal cytology in the prior 12 months. Only 7.7% (95% CI = 5.1% to 10.6%) of gay, bisexual, and other men who have sex with men as well as transgender women 35 years of age or older and 1.9% (95% CI = 0.9% to 2.9%) of all other people with HIV aged 45 years and older had anal cytology. Prevalence was statistically significantly low among people with HIV with the following characteristics: non-Hispanic or Latino, Black or African American, high school education or less, heterosexual orientation, and living in southern Medical Monitoring Project states. Among people with HIV, 32.8% (95% CI = 28.0% to 37.7%) had no access to high-resolution anoscopy on-site or through referral at their care facility; 22.2% (95% CI = 19.5% to 24.9%) had on-site access; 45.0% (95% CI = 41.5% to 48.5%) had high-resolution anoscopy available through referral. Most facilities that received Ryan White HIV/AIDS Program funding, cared for more than 1000 people with HIV, or provided on-site colposcopy also provided high-resolution anoscopy on-site or through referral.

CONCLUSIONS

Rates of anal cytology and access to high-resolution anoscopy were low among people with HIV, including those individuals at highest risk of anal cancer. Our data may inform large-scale implementation of anal cancer prevention efforts.

Anal Dysplasia Screening in People Living with HIV: Long-Term Follow-Up in a Large Cohort from Northwest Spain

Anal squamous cell carcinoma (SCC) is not a common disease in the general population, although its incidence is higher in people living with human immunodeficiency virus (PLWH). Anal SCC is caused by human papillomavirus (HPV) infection and arises from premalignant lesions termed squamous intraepithelial lesions (SILs). SIL surveillance programs are based on the early detection and treatment of SILs, especially those with a higher risk of transforming into cancer. An anal surveillance program has been under development in our institution since 2011. In this context, we performed a retrospective cohort study at the anal dysplasia unit of Álvaro-Cunqueiro Hospital (Spain). Epidemiological and clinical data were gathered from our Infectious Diseases Sample Collection (an open sample cohort including PLWH) from January 2011 to January 2022. A total of 493 PLWH were considered, 122 (24.7%) of whom were diagnosed with anal dysplasia at baseline, including 2 cases of anal SCC. Briefly, most of individuals were young men (median age, 38 years old) born in Spain (76%), whose vaccination rate before their inclusion in the program was scarce (<3%). Throughout the study period, 81 (16.4%) cases were diagnosed with high-grade squamous-intraepithelial lesions (HSILs) and 3 with anal SCC. At the baseline, severe immunosuppression (i.e., nadir CD4+ lymphocyte count below 200 cell/μL), and prior diagnosis of condyloma acuminata were more frequent within the group with SILs. Conversely, the baseline CD4+ lymphocyte count was similar among both groups. HPV-16 was related to a higher risk of HSILs (odds ratio: 2.76). At the end of the follow-up, 385 PLWH had been retained in care; one patient had died of anal cancer. Anal dysplasia was common (25% of cases), especially among patients infected by HPV-16, diagnosed with condyloma acuminata, and who were severely immunosuppressed. HPV-16 was the main risk factor for the presentation of HSILs.

A Qualitative Study of Barriers to Anal Cancer Screenings in US Veterans Living with HIV

People living with human immunodeficiency virus (HIV) are at high risk for anal cancer. Anal cancer screenings are recommended annually for US veterans with HIV. Screenings can identify treatable precursor lesions and prevent cancer development. In a previous study, we found screening rate to be only 15%. Semistructured interviews were conducted with Veterans Affairs (VA) providers who treat veterans living with HIV. Participants described their experiences with anal cancer screenings. Researchers developed a codebook based on Theoretical Domains Framework (TDF) and coded data using thematic analysis to identify barriers to anal cancer screenings. Twenty-three interviews were conducted with VA providers representing 10 regions. Barriers identified corresponded with five targetable TDF domains: Knowledge, Skills, Environmental Context/Resources, Professional Roles/Identities, and Social Influence. Many providers lacked knowledge of screening protocols. Knowledgeable providers often lacked needed resources, including swabs, clinic space, reliable pathology, access to high-resolution anoscopy, or leadership support to implement a screening program. Providers mentioned competing priorities in the care of veterans with HIV infection and lack of skilled/trained personnel to perform the tests. It was often unclear which provider specialty should "own" screening responsibilities. Additional factors included patient discomfort with screening exams. Anal cancer screening protocols are recommended but not widely adopted in VA. There is a critical need to address barriers to anal cancer screenings in veterans. The TDF domains identified align with five intervention domains to target, including education, training, resource/environment, delineation of provider roles, and improved counseling efforts. Targeting these barriers may help improve the uptake of anal cancer screenings within VA.