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

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.