Studies estimate that transgender women (TGW) have a high prevalence of high-risk HPV (HR-HPV) and anal intraepithelial lesions (1), and early intervention improves outcomes (2). We examined risk factors associated with anal dysplasia (AD) and linkage to high resolution anoscopy (HRA) in a sample of TGW with and without HIV.
We recruited a convenience sample of TGW in DC from 4/2021–9/2022. Data collected included: demographics; serum samples; anal swabs for cytology and HPV genotyping. We defined AD as a cytology diagnosis of atypical squamous cells of undetermined significance, low-grade or high-grade intraepithelial lesions (HSIL). Current use of gender affirming hormones (GAH) was defined as self-report of use, or serum estradiol level higher than 60 pg/mL (estrogen) and a testosterone level below 264 ng/dL (androgen blocker). Participants with AD were scheduled for off-site HRA. We used chi-square tests to compare differences between AD risk factors.
Of 62 TGW with adequate anal cytology samples, most were black (87%), stably housed (55%), engaged in anal receptive sex within 12 months (77%), and on GAH (56%). Only 12 (19%) recalled receiving an HPV vaccine. Of 43 (69%) patients with HIV, 15 (35%) had HIV viral load >200 copies/mL, median CD4 count was 619, and 22 (47%) had previous anal cancer screening.AD was found in 29 (47%), while 45 (74%) tested positive for HR-HPV. AD was associated with the presence of HR-HPV (p=0.04), and with black race (p=0.03), but was not significantly associated with current GAH use or HIV status (Table 1). In TGW with HIV, HIV viremia was not associated with a higher risk of AD: 10 (44%) AD with viremia and 13 (56%) AD in those without (p=0.2).Of all TGW with AD, 23 (79%) had HRA scheduled, but only 6 (26%) attended, with HSIL found in 2 patients. A year after initial screening, 16 TGW had repeat anal samples collected. On repeat, 4 (25%) cleared anal HR-HPV, and 4 (25%) no longer had AD, including one with known HSIL on HRA.
Our findings highlight the high prevalence of HR- HPV and AD in TGW regardless of HIV status, HIV suppression, age or use of GAH. In this high-risk population, we found low rates of prior HPV vaccination, and limited HRA attendance despite facilitated linkage. Future studies should identify longitudinal risk factors for persistence of HR-HPV or AD, and strategies for enhancing HPV vaccination, anal cancer screening, and linkage to HRA in TGW.
Table 1: Association of risk factors with abnormal anal cytology.