Challenges and limitations of anal cancer and precancer screening among people with HIV in a real-world setting.

PURPOSE: Anal carcinoma (AC) incidence in people with HIV (PWH) is increasing. Guideline-recommended anal-cytology screening facilitates early treatment of precancerous lesions. Data on real-world adherence to screening- and follow-up (F/U)-recommendations remain limited.

METHODS

We analyzed routine anal-cytology screening in PWH at a German university hospital-clinic (2017-2023), including frequency of findings, F/U, and final diagnoses.

RESULTS

The study-population included 434 persons with 936 anal-cytology results, representing 25% of person-time of F/U at our clinic. Median age was 55 years, female/male ratio was 5/429, 310 (71%) were MSM. Median CD4-nadir was 242/µl, in 97% viral load was suppressed, 47% were currently smoking. Of 936 swab-results, 882 (94%) were evaluable; 201 (21%) showed abnormalities. Among these, 60 (30%) were ASC-US, 77 (38%) LSIL, 12 (6%) ASC-H, and 52 (26%) HSIL. High-resolution-anoscopy (HRA), recommended for the 64 ASC-H/HSIL-cases, was performed in 7 (11%), identifying 1 AIN2. In 46/64 (72%) proctoscopy identified 1 AC and 3 cases each of AIN2/AIN3. Eleven persons (17%) refused F/U. Thus, 8/64 (12.5%) suspicious cytology findings were histopathologically confirmed. During the study period, 4 cases of AC were diagnosed in unscreened persons at our clinic.

CONCLUSION

Routine anal-cytology screening in an unsystematically selected cohort of 434 PWH contributing 1,383 person-years of F/U identified 7 cases of high-grade precancerous lesions and 1 asymptomatic AC. Important challenges included low uptake, limited specificity of cytology, inconsistent adherence to F/U recommendations, and insufficient availability of HRA. Improved communication of HIV-care-providers with all involved parties will be a key requirement for improving efficiency and outcomes.