Human papillomavirus-associated anal squamous intraepithelial lesions in men who have sex with men and transgender women living with and without HIV in Karachi Pakistan: implications for screening and prevention

Integration of human papillomavirus associated anal cancer screening into HIV care and treatment program in Pakistan: perceptions of policymakers, managers, and care providers

BACKGROUND

The incidence of anal cancer, largely associated with anal human papillomavirus (HPV) infection, is increasing among men who have sex with men (MSM), and transgender women living with or without HIV. Screening for anal cancer to detect anal precancerous lesions in high-risk groups is an important opportunity for prevention but still lacking in many low-and-middle-income countries. The aim of this study was to explore the readiness of Pakistan's healthcare system to integrate anal cancer and HPV screening into a national HIV program, as perceived by policymakers, health managers, and healthcare providers.

DESIGN

This qualitative study using key-informant interviews with participants influence in policy making, implementation and advocacy from public and private sector were conducted between March 2021 to August 2021 in Karachi Pakistan.

METHODS

Key informants were purposely selected from different domains of the healthcare system responsible for the target group of interest, MSM and transgender-women in general and people living with HIV in particular. A total of 18 key informants, at different levels of seniority were recruited from governmental and non-governmental organizations, high-level infectious disease healthcare managers, and United Nations Program representatives. Qualitative content analysis was used to identify the manifest and latent themes, based on socioecological framework.

RESULTS

The results were grouped into five major themes; (1) The policy context and priorities, (2) Health systems factors, (3) Community environment, (4) Healthcare setting & providers and (5) Individual-level obstacles. The policy actors expressed their concerns about their limited voice in country's health and health related priority setting. Informants reported a lack of political will and suggested that government should bring a change in the paradigm of healthcare service delivery from reactive to proactive approach. Although, participants unanimously favored integration of HPV preventive services into existing HIV program, they also identified several service delivery barriers including trained workforce shortage, limited capacity of information technology, lack of supplies needed for screening, lack of financing, and lack of services that could meet key-populations needs. Participants also predicted other implementation challenges such as stigma, social victimization, and systemic discrimination against at-risk groups at healthcare facilities.

CONCLUSION

Although policy makers and health providers in Pakistan saw a clear need to scale-up and integrate anal cancer screening for key populations, the feasibility of this is dependent on political will, financing, anti-stigma and discrimination interventions and health system efficiency.

Advances and challenges in sexually transmitted infections prevention among men who have sex with men in Asia

PURPOSE OF REVIEW

This review summarizes recently published research on sexually transmitted infections (STIs) and sexually transmitted diseases (STDs) among men who have sex with men (MSM) in Asia, covering four main areas: prevalence and consequences of STIs/STDs, factors associated with STI risk, strategies and measures of STI prevention, challenges in the prevention of SITs.

RECENT FINDINGS

Studies show that STIs among Asian MSM are still prevalent, with the prevalence of STIs varying slightly from country to country. In addition to the number of sexual partners, frequency of condom use, high-risk sexual behaviors, the influence of Confucianism, law, and COVID-19 are also related to STI risk. Social stigma, weak health systems, lack of funding and policy support are the current challenges for STIs prevention.

SUMMARY

In the future, new media technologies are encouraged to be used to enhance education and reduce stigma and discrimination against MSM and STIs. Expanding STI screening, strengthening STI knowledge propaganda and education among MSM population, and providing necessary counseling and medical services are main strategies in STI prevention. It is also important to strengthen STI awareness and policy support at the national level.

Development of a multivariable prediction model for anal high-grade squamous intraepithelial lesions in persons living with HIV in Puerto Rico: a cross-sectional study

Background

Persons living with HIV (PLWH) are at high risk of developing anal high-grade squamous intraepithelial lesions (HSIL). We aimed to develop a prediction model for anal HSIL based on individual characteristics of PLWH.

Methods

Cross-sectional study of PLWH aged ≥21 years who attended the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Cancer Center from 2016 to 2022. The primary outcome was biopsy-confirmed anal HSIL. For each sex, relations between potential predictors and HSIL were examined using univariate (ULRM) and multivariable (MLRM) logistic regression models. Risk modelling was performed with MLRM and validated with bootstrapping techniques. The area under the ROC Curves (AUC) was estimated with 95% CI.

Findings

HSIL was detected among 45.11% of patients, 68.48% were males, and 59.42% were ≥45 aged. Multivariable analysis showed that, in women, the only significant predictor for HSIL was having a previous abnormal anal cytology (p = 0.01). In men, significant predictors for HSIL were having a previous abnormal anal cytology (p < 0.001) and a history of infection with any gonorrhoea (p = 0.002). Other suggestive predictors for HSIL among women were obesity and smoking. No association between smoking and HSIL among men was observed (p < 0.05). The AUC estimated among women (0.732, 95% CI: 0.651-0.811) was higher than in men (0.689, 95% CI: 0.629-0.748).

Interpretation

Our results support that the inclusion of individual characteristics into the prediction model will adequately predict the presence of HSIL in PLWH.

Funding

This work was supported by the NCI (Grants #U54CA096297, #R25CA240120), the NIGMS (Grant #U54GM133807), and the NIMHD (Grant #U54MD007587).