Background: HIV-infected patients have a higher burden of HPV associated high-grade squamous intraepithelial lesions (HSIL) and anal cancer. Guidelines for anal cancer screening in HIV-infected women in New York State include a history of abnormal cervical and/or vulvar histology or history of anogenital warts. The HIV Medical Association of IDSA (HIVMA) screening guidelines include these and add “or a history of receptive anal intercourse” to the criteria as another indication. Best practices for this population are poorly defined. Here we report outcomes and associated risk factors for HSIL in HIV-infected women over five years after implementation of a program which offers anal cancer screening by means of anal cytology to all HIV-infected women regardless of previous HPV disease or sexual behavior.
Methods: Data from women who underwent high resolution anoscopy (HRA) following abnormal anal cytology from April 2009 to July 2014 were reviewed. All HRA were performed by a single operator. Routine clinical data included cervical PAP history, demographics, behavioral data, and HRA results. Chi square tests were used for comparisons.
Results: 306 HIV-infected women underwent HRA, median age was 47, mean CD4 was 537 cells/mm3, 67% had HIV viral loads <50, 72% had a history of abnormal cervical PAP, and 66% reported a history of anal receptive intercourse. HSIL was found in 28% of anal biopsies. 49% of the 55 women who did not meet criteria for anal cancer screening according to NYS guidelines had anal dysplasia on biopsy. 13 of the 55 women (24%) had HSIL requiring treatment, including one subject with minimally invasive carcinoma. Using HIVMA recommendations, an additional 35 patients met criteria for anal cancer screening. Four of the 20 women (20%) who did not meet screening criteria by either guideline had HSIL on biopsy. Neither meeting NYS criteria, HIVMA criteria, nor a history of receptive anal intercourse as the sole criterion were significantly associated with a diagnosis of HSIL (p=0.079, 0.403, and 0.093 respectively). A history of smoking was the only factor associated with HSIL on biopsy (p=0.002).
Conclusions: Anal HSIL was commonly found in HIV-infected women in this cohort. A high rate of dysplasia on biopsy was found even among women who did not meet criteria for routine screening. These results support that all HIV infected women may benefit from anal cancer screening regardless of their cervical / genital HPV history or sex practices.