Exploring the Perceptions of Anal Cancer Screening and Behaviors Among Gay and Bisexual Men Infected With HIV

Men who have sex with men experience low anxiety and few barriers to performing anal self or companion examinations: a qualitative study of the Prevent Anal Cancer Palpation Study

While rare in the larger population, anal cancer incidence is significantly higher in groups such as sexual minority men and people living with HIV. This qualitative analysis examined participants' experiences and perceptions of barriers to anal self-examination and anal companion examination through interviews completed as a part of a larger clinical trial. Interviews were conducted online with participants (n = 131) within a week of their baseline appointment between January 2020 and October 2021. Content analysis denoted participants' thoughts and perceptions about anal self-examination and anal companion examinations. Of the 131 cisgender men interviewed (mean age 49.9 years, SD 12.7), 92.4% identified as gay, 54.9% identified as white, 22.1% identified as Black, 19.9% identified as Latino, and 44.3% of participants were living with HIV. Participants did not report feelings of excessive anxiety when an abnormality was detected. However, three salient themes emerged as to why participants may not perform an anal self-examination or anal companion examination: (1) physical limitation(s), (2) potential sexualisation of the examination, and (3) level of comfort discussing anal health. Future work must continue to explore methods that not only decrease stigma surrounding anal health but also bolster feelings of accessibility to perform self and couple examinations.

Endoscopic underwater detection and resection of anal squamous intraepithelial lesions in non-anesthetized patients - a feasibility study and comparison with standard surgical treatment

BACKGROUND

Anal squamous intraepithelial lesions (ASILs) correspond to premalignant changes preceding the development of anal squamous cell carcinoma.

OBJECTIVE

To describe a new endoscopic technique to detect and remove ASILs in non-anesthetized patients and compare it with standard surgical treatment.

METHODS

For endoscopic treatment, high resolution (HR) flexible endoscopes with a distal attachment were used. Underwater inspection of the anal canal was performed in near-focus mode with white light and narrow-band imaging. Detected lesions were resected with a diathermia snare after local injection of xylocaine/adrenaline. We did a retrospective comparison of all patients who underwent endoscopic or standard surgical treatment for ASILs at Ersta hospital in Stockholm between 2018 and 2020. Patient files were reviewed for number of lesions, treatments until macroscopic radicality, degree of dysplasia, bleeding, pain and other complications.

RESULTS

Endoscopic (n = 37) and surgical (n = 43) treatment displayed comparable number of lesions per patient (p = .37). The number of procedures until macroscopic radicality was higher for endoscopy than surgery (p = .04). However, in endoscopic follow up of 12 of the surgically treated patients, residual ASIL was found in 10 cases. Post-procedural bleeding requiring healthcare occurred in two endoscopy patients and one surgically treated patient.

CONCLUSIONS

Underwater resection using a HR flexible endoscope in non-anesthetized is a new, feasible and well tolerated method for ASILs treatment. Its efficacy and risk of complications seem comparable to standard surgical treatment while avoiding general anesthesia. However, minor lesions might be overlooked at surgery.

Knowledge and Perceived Emotions Regarding an Anal Cancer Preventive Program in People Diagnosed With HIV: A Qualitative Study

BACKGROUND

To the best of our knowledge, no studies have yet examined the emotional repercussions of the care processes among people infected with the human immunodeficiency virus who participate in preventive anal cancer screening programs.

OBJECTIVE

This study aimed to explore the knowledge, emotions, sexuality, barriers, and facilitators perceived by this patient group during the process of anal cancer screening and diagnosis.

METHODS

Detailed, semistructured, qualitative interviews were completed with 17 men and 3 women to explore their knowledge, experiences, and emotions regarding the screening process. Purposive sampling was conducted on the basis of age, gender, and type of lesion diagnosed in the anal biopsy.

RESULTS

Four major themes were identified: 1) knowledge of the disease and its treatment, 2) emotions perceived by the patients, 3) the influence of screening on sexual practices, and 4) facilitators and obstacles during the care provision process. Patients reported appropriate knowledge of anal cancer and human papillomavirus. Predominant emotions were worry and fear with avoidance as one of the coping strategies.

CONCLUSION

These results suggest that communication of information and clinical results can be improved.

IMPLICATION FOR PRACTICE

Understanding the facilitators and barriers to the program will allow the integration of interventions designed to improve healthcare provision into direct care.

Barriers and facilitators to anal cancer screening among people living with HIV in Puerto Rico

BACKGROUND

Anal cancer (AC) disproportionally affects people living with HIV (PLWH). Although there are no consensus-based AC screening guidelines, experts recommend anal pap as a primary screening tool in settings where high-resolution anoscopy (HRA) is available. We aimed to assess barriers and facilitators to anal cancer screening in a sample of Hispanic PLWH in Puerto Rico.

METHODS

To assess their knowledge and attitudes, we conducted a cross-sectional survey from 2020-2021 among PLWH in Puerto Rico (n = 212). Data was collected through a telephone interview that assessed information on sociodemographics, knowledge, and attitudes about AC, and the history of AC screening. The chi-square test, Fisher exact test, and logistic regression models were used to assess factors associated with screening uptake.

RESULTS

Anal Pap and HRA awareness were 60.4% and 30.7%, respectively. Anal Pap and HRA uptake was 51.5% and 19.3%, respectively. The most common barriers for anal Pap and HRA were lack of knowledge about the test and lack of physician recommendation. MSM were more likely to have heard of anal Pap (OR: 2.15, 95% CI:1.30-3.54) than MSW. MSM (OR: 3.04, 95% CI: 1.79-5.19) and women (OR: 3.00, 95% CI: 1.72-5.20) were also more likely to have undergone anal Pap. Similarly, individuals with a history of genital warts were more likely to have heard of anal Pap and HRA and have undergone anal Pap and HRA. Awareness of where to go for concerns about anal health was positively associated with having received anal Pap and HRA.

CONCLUSIONS

With emerging evidence on the effectiveness of screening and treatment for anal cancer, several organizations are steering toward generating consensus-based anal cancer screening recommendations. Our study provides foundational data on barriers and facilitators to anal cancer screening in Puerto Rico that will be critical to informing screening implementation in this US territory.

Home-based self-sampling vs clinician sampling for anal precancer screening: The Prevent Anal Cancer Self-Swab Study

Sexual minority men are at increased risk for anal squamous cell carcinoma. Our objective was to compare screening engagement among individuals randomized to self-collect an anal canal specimen at home or to attend a clinic appointment. Specimen adequacy was then assessed for human papillomavirus (HPV) DNA genotyping. A randomized trial recruited cisgendered sexual minority men and transgender people in the community and assigned them to use a home-based self-collection swabbing kit or attend a clinic-based swabbing. Swabs were sent for HPV genotyping. The proportions of participants completing screening in each study arm and the adequacy of their specimens for HPV genotyping were assessed. Relative risks were estimated for factors associated with screening. A total of 240 individuals were randomized. Age (median, 46 years) and HIV status (27.1% living with HIV) did not differ by study arm. A total of 89.2% and 74.2% of home-arm and clinic-arm individuals returned the swab, respectively (P = .003), difference between groups, 15.0% (95% CI 5.4%-24.6%). Among black individuals, 96.2% and 63.2% in the home and clinic arms screened (P = .006). Among individuals with HIV, 89.5% and 51.9% in the home and clinic arms screened (P < .001). Self-collected swabs and clinician-collected swabs were comparable in adequacy for HPV genotyping (96.3% and 93.3%, respectively). People at highest risk for anal cancer may be more likely to screen if they are able to self-collect swabs at home rather than attend a clinic.

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.

Anal Cancer Screening and Prevention: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infection Guidelines

In June 2019 the Centers for Disease Control and Prevention (CDC) convened an advisory group to assist in development of the 2021 CDC sexually transmitted infections (STI) guidelines. The advisory group on anal cancer screening and prevention met to formulate key questions in this field. The group examined published literature and abstracts to assess evidence and give recommendations for development of the CDC guidelines. This article summarizes key questions, evidence, recommendations, and areas for further research for the screening, diagnosis, and prevention of anal cancer.

Gay and Bisexual Men Who Report Anal Sex Stigma Alongside Discomfort Discussing Anal Sex with Health Workers Are Less Likely to Have Ever Received an Anal Examination or Anal Swab

Purpose: We sought to determine whether stigma toward anal sexuality was associated with having ever received an anal examination or anal swab among gay and bisexual men (GBM). Methods: In 2017, we conducted a cross-sectional online survey with 1513 adult cisgender GBM living in the United States. We used structural equation modeling to test whether the Anal Sex Stigma Scales (a validated measure comprising provider stigma, self-stigma, and silence) was negatively associated with lifetime receipt of anorectal examination or anal swabbing by a medical provider. The model assessed mediation by respondents' comfort discussing anal sex practices with health workers and adjusted for possible confounders. Results: As hypothesized, anal sex stigma was associated with less comfort discussing anal sex (β = -0.44, 95% confidence interval [CI]: -0.50 to -0.38, p < 0.001), and greater comfort was associated with greater likelihood of screening (β = 0.28, 95% CI: 0.19 to 0.37, p < 0.001). The model demonstrated good fit (root mean square error of approximation = 0.045, comparative fit index, and Tucker-Lewis index each = 0.99) and adjusted for everyday discrimination, social support specific to anal sex, age, income, education, medical coverage, outness, and ethnic/racial identification. Collectively, model variables accounted for 48% of the variance in screening (p < 0.001). Conclusion: GBM who endorsed less anal sex stigma reported greater comfort discussing anal sex with health workers and were more likely to have ever received anal health screening by a medical provider. To improve anal health and cancer prevention among GBM, anal sex stigma and related discomfort discussing anal sex with health workers are targets for intervention.

Administering the HPV Vaccine to People Living with HIV: Providers' Perspectives

HIV-positive patients suffer disproportionate burden of anal cancer, a disease which is primarily caused by persistent infection with human papillomavirus (HPV) and is potentially preventable with the completion of the HPV vaccine series. Past research qualitatively explored HIV-positive patients' perspectives about the HPV vaccine. However, little is known about their healthcare practitioners' vaccine recommendation behaviors, the strongest influence on vaccine uptake. This study reports on in-depth interviews conducted with 25 healthcare practitioners who provide care for HIV-positive patients. Qualitative themes that emerged from the study included clinicians' HPV vaccination behaviors, HIV patient's willingness to get the HPV vaccine, the role of HIV-positive patients' immune functioning in terms of timing of HPV vaccine administration, and vaccinating HIV-positive patients over age 26. The majority of providers offered the vaccine at their healthcare facility. Participants varied in their opinions related to the importance of patients' CD4 count in terms of timing of HPV vaccine administration; some believed that patients' immune functioning should first be stabilized to receive the most benefit from the vaccine series. They also differed in the perceived benefit of offering the vaccine to patients over age 26. In light of the U.S. Food and Drug Administration's recent approval to extend HPV vaccination to adults up to age 45 years, more HIV-positive adults may benefit by receiving this vaccine series. Future efforts should ensure that providers regularly promote the HPV vaccine to their adult HIV-positive patients. Vaccinating HIV-positive patients may help reduce the burden of HPV-related cancers, particularly anal cancer.

Factors associated with anal cancer screening uptake in men who have sex with men living with HIV: a cross-sectional study

Most western countries have guidelines on anal cancer screening for men who have sex with men (MSM) living with HIV. However, adherence to these guidelines has been studied poorly. This cross-sectional study reports anal cancer screening uptake and identifies the factors associated with a previous screening in MSM living with HIV in a Paris Hospital (France). A total of 410 outpatients completed a self-administered questionnaire on anal cancer screening. The median age was 50 years and the median time from HIV diagnosis was 14.2 years. Overall, 82.2% of patients were aware of anal cancer screening and, of these, 56.7% had already undergone a screening test. The absence of history of screening (43.3%) was most often explained by lack of time (31.3%) or information (28.2%). Among patients familiar with the anal screening procedure, those older than 50 years (adjusted odds ratio=2.4, 95% confidence interval=1.3-4.7, P=0.007) and informed by healthcare providers (adjusted odds ratio=8.2, 95% confidence interval=2.5-32.0, P=0.001) were more likely to have already been screened. To date, adherence to anal cancer screening in MSM living with HIV appears to be inadequate to enable diagnosis of cancer at its early stages. Encouraging physicians to inform MSM living with HIV about anal cancer screening, irrespective of their age, could be an effective strategy to improve anal cancer screening uptake.

Racial Disparities in Anal Cancer Screening Among Men Living With HIV: Findings From a Clinical Cohort Study

BACKGROUND

Our objective was to quantify the extent of anal cancer screening among men receiving HIV specialty care in Ontario, Canada, and evaluate factors associated with screening.

SETTING

Cross-sectional questionnaire within a multisite clinical HIV cohort.

METHODS

A questionnaire assessing knowledge and experience with human papillomavirus-associated diseases and their prevention was administered in 2016-2017 to 1677 men in the Ontario HIV Treatment Network Cohort Study. We used logistic regression to identify factors associated with having discussed screening with a health care provider and self-reported receipt of screening [digital anal rectal examinations (DARE); anal cytology or anoscopy]. Results reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

Forty percent of men reported ever having had anal cytology/anoscopy, and 70% had ever had DARE. After accounting for differences in age, sexual orientation, years since HIV diagnosis, previous diagnosis with AIDS, knowing someone with human papillomavirus-associated cancer, comfort discussing anal health, education, and income, the proportion screened differed by self-identified race. Compared with white men, Asian men were less likely to have discussed screening with a health care provider (aOR = 0.48; 95% CI: 0.29 to 0.80) or to have been screened by DARE (aOR = 0.27; 95% CI: 0.17 to 0.44) or anal cytology/anoscopy (aOR = 0.51; 95% CI: 0.31 to 0.83), and African, Caribbean, or black men (aOR = 0.47; 95% CI: 0.31 to 0.70) were less likely to have had DARE. Results were consistent when restricting the analyses to gay, bisexual, and other men who have sex with men.

CONCLUSION

Our findings highlight the potential for disparities in anal cancer screening that need to be considered when developing guidelines and screening programs to reduce the burden of anal cancer among men living with HIV and ensure health equity.

"That's Only for Women": The Importance of Educating HIV-Positive Sexual Minority Men on HPV and High Resolution Anoscopy (HRA)

Gay, bisexual, and other men who have sex with men (MSM) experience disproportionately high burdens of Human Papilloma Virus (HPV)-associated anal cancers. Recent focus has shifted to anorectal cancer prevention through high-resolution anoscopy (HRA); however, little is known about sexual minority men's perceptions, attitudes, or beliefs regarding HRA. We conducted 4 qualitative Focus Group Discussions (FGDs) (n = 15) with sexual minority men, focusing on their beliefs, attitudes, and perceptions of undergoing HRA. Participants discussed their experiences of HPV/HRA as influenced by both their gender and sexuality, including unawareness of HPV disease as a male health issue, challenges relating to female-oriented HPV/HRA language, conception of HPV/HRA as related to prostate health, and connecting their sexual behavior identification as "bottoms" to their need for HRA. As efforts to improve HRA knowledge, access, and uptake among sexual and gender minority communities increase, special attention should be paid to language and messaging choices around HRA.

Racial/Ethnic Disparities in Survival Among Women Diagnosed with Invasive Cancer of the Anal Canal: an Analysis of Surveillance, Epidemiology, and End Results (SEER) Data

OBJECTIVE

To identify differences in survival among women diagnosed with cancer of the anal canal from varying racial and ethnic backgrounds.

METHODS

Data from the Surveillance, Epidemiology and End Results (SEER) registry between the years of 1975 and 2016 were analyzed, which included 19,048 women with cancer of the anal canal. Multivariable Cox proportional hazard regression (HRs) was performed to examine the relative risk of dying among women with anal cancer. Multivariable odds ratios (ORs) with 95% confidence intervals (CIs) were used to examine odds of highly fatal disease (death within 12 months from diagnosis).

RESULTS

Non-Hispanic Black women (n = 1694) had greater risk of dying when compared with non-Hispanic White women (n = 15,821) with anal cancer (HR = 1.26, CI: 1.17-1.35), independent of other prognostic indicators. Stratifying by age at diagnosis, risk of death was highest for non-Hispanic Black women diagnosed younger than age 50 years compared with non-Hispanic White women of similar age (HR = 1.60, CI: 1.34-1.89), and lowest for Hispanic women (n = 1533) older than 74 years at diagnosis (HR = 0.80, CI: 0.69-0.92). Stratifying by stage at diagnosis, disparities were not observed. When comparing across years of diagnoses, non-Hispanic Black women consistently had poorer survival compared with non-Hispanic White women diagnosed in the same year intervals. Finally, non-Hispanic Black women had greater odds of highly fatal disease (OR = 1.23, CI: 1.08-1.40) compared with non-Hispanic White women.

CONCLUSION

Non-Hispanic Black women with anal cancer continue to experience poorer survival compared with non-Hispanic White women, whereas disparities were not identified for Hispanic women.

Investigating epidemiologic trends and the geographic distribution of patients with anal squamous cell carcinoma throughout Canada

Background

Anal cancer is a rare disease, constituting 0.5% of new cancer cases in the United States. The most common subtype is squamous cell carcinoma (scc). Studies in several developed nations have reported on an increasing incidence of anal cancer in recent decades, and various risk factors pertaining to the pathogenesis of the disease have been identified, including infection with the human papillomavirus, tobacco use, and immunosuppression. The epidemiology and distribution of anal scc throughout Canada remain poorly understood, however.

Methods

Using 3 population-based cancer registries, a retrospective analysis of demographic data across Canada for 1992-2010 was performed. The incidence and mortality for anal scc was examined at the levels of provinces, cities, and the forward sortation area (FSA) component (first 3 characters) of postal codes.

Results

During 1992-2010, 3720 individuals were diagnosed with anal scc in Canada; 64% were women. The overall national incidence rate was 6.3 cases per million population per year, with an average age at diagnosis of 60.4 years. The incidence increased over time, with significantly higher incidence rates documented in British Columbia and Nova Scotia (9.3 cases per million population each). Closer examination revealed clustering of cases in various urban centres and self-identified lgbtq communities in Toronto, Montreal, and Vancouver.

Discussion

This study provides, for the first time, a comprehensive analysis of the burden of anal scc in Canada, identifying susceptible populations and shedding light onto novel avenues of research to lower the incidence of anal cancer throughout the country.

Early Outcomes of a High-Resolution Anoscopy-Based Anal Cancer Screening Program Among People With HIV Enrolled in an Integrated Health Care System

BACKGROUND

Few studies have examined outcomes of high-resolution anoscopy (HRA)-based screening for people with HIV infection (PWH), a population at increased risk for anal cancer.

SETTING

Large integrated health care system.

METHODS

Cohort study of 13,552 people with HIV infection, comparing incidences of anal cancer and advanced anal cancer (higher stage, recurrence, death, or surgical salvage) before and after HRA became available (2008). Calendar time was divided as 1998-2007, 2008-2010, and 2011-2012. Rate ratios (RRs) were obtained from Poisson regression models with adjustment for baseline demographic and health variables. Cohort cases during 2008-2012 were included in a nested case-control study, evaluating association of screening with anal cancer (33 cases, 330 controls) and advanced anal cancer (19 cases, 190 controls). Odds ratios (ORs) for receipt of screening were obtained from conditional logistic regression models with adjustment for baseline demographic and health history variables.

RESULTS

Compared with 1998-2007 (pre-HRA), 2008-2010 adjusted RRs were 1.32 [95% confidence intervals (CI): 0.77 to 2.27; P = 0.31] for anal cancer and 2.11 (95% CI: 0.99 to 4.48; P = 0.053) for advanced anal cancer; and 2011-2012 adjusted RRs were 0.35 (95% CI: 0.12 to 0.99; P = 0.048) for anal cancer and 0.23 (95% CI: 0.03 to 1.77; P = 0.16) for advanced anal cancer. Individual history of screening did not reach statistical significance for anal cancer (OR 1.7; 0.6-4.6) or advanced anal cancer (OR 0.44; 0.1-3.8).

CONCLUSIONS

Despite the possible effect of secular trends, we found 2008-2012 incidence trends for anal cancer and advanced anal cancer that seem consistent with expected findings of a beneficial screening program.

Satisfaction with high-resolution anoscopy for anal cancer screening among men who have sex with men: a cross-sectional survey in Abuja, Nigeria

Background

Men who have sex with men (MSM) living with HIV are at increased risk for anal cancer. We evaluated satisfaction with first-time anal cancer screening using high resolution anoscopy (HRA) as a cross sectional survey among men who have sex with men (MSM) attending a community-engaged clinic in Abuja, Nigeria.

Methods

Between March and August 2017, 342 MSM underwent screening and 307 (89%) completed a satisfaction survey that evaluated 8 domains related to expectations, convenience, staff interpersonal skills, physical surroundings, technical competence, pain/discomfort, general satisfaction, and intention to re-screen if symptomatic. The 22-item questionnaire used 5-point Likert scales ranging from 1 (strongly disagree) to 5 (strongly agree). For each domain, responses to specific items were averaged, aggregated, and converted to a 100-point scaled score (SS) with 25 and 75 corresponding to disagree and agree, respectively.

Results

Median age was 24 years (interquartile range [IQR]: 22–28), median years since anal coital debut was 7 (IQR: 4–12), and 58% (95% confidence interval [CI]: 52–64%) were living with HIV. Despite respondents reporting pre-procedure anxiety (SS:73), most were comfortable with the setting and procedure and reported overall satisfaction (SS:74–76). Willingness to undergo future screening had the lowest score (SS:69) within the general satisfaction domain. The lowest scoring domains were pain/discomfort (SS:57) and agreement to re-screen if symptomatic (SS:59), which correlated with lower overall satisfaction (p < 0.001). Domain responses did not differ by HIV infection after adjusting for multiple comparisons (p > 0.006) or number of anal biopsies (all p > 0.05).

Conclusions

Overall, HRA was satisfactory for those naïve to screening but moving forward necessitates monitoring levels of discomfort with pain scales and normalizing dialogue around clinical symptoms of anal cancer and overall anal health to sustain future screening.

Establishing an Anal Cancer Screening Program in an Outpatient HIV Clinic: Referral Patterns and Patient Perceptions Survey

People living with HIV are at high risk for anal cancer (AC); however, the impact of screening for and treatment of precancerous anal lesions on AC incidence remains uncertain. In 2013, we conducted a survey of HIV providers evaluating the perceived need for an institutional AC screening program. Based on an overwhelmingly positive response, we established a dedicated AC screening clinic (including provision of high-resolution anoscopies) embedded within the institutional HIV clinic. Here, we describe that referral of high-risk patients in the first 3 years was lower than expected. Referral patterns suggest that screening practices vary widely among HIV providers within the institution. Anal cancer clinic patients who completed a perception survey rated the value of AC screening as high, with perceived positive health impact, and identified their providers as the main source of information on AC and AC screening. Our findings imply remaining provider-related barriers to AC screening.

Facilitators of and barriers to high-resolution anoscopy adherence among men who have sex with men: a qualitative study

Background Anal cancer is a rare malignancy that disproportionately affects men who have sex with men (MSM) and HIV-infected people. Anal cancer is associated with human papillomavirus (HPV) in upward of 90% of cases and is preceded by pre-cancerous changes in cells of the anal canal. High-resolution anoscopy (HRA) is used for the detection, treatment and continued monitoring of anal dysplasia. Practice guidelines regarding anal cancer prevention vary by jurisdiction and institution, and patient engagement is low for high-risk populations such as MSM. The purpose of this study is to characterise perceptions among MSM of barriers to and facilitators of their adherence to HRA follow-up recommendations.

METHODS

Surveys and in-person focus groups with MSM who were either adherent or non-adherent to HRA follow-up recommendations at a Federally Qualified Health Centre in Boston, MA, which specialises in sexual and gender minority care, were conducted. Facilitators of and barriers to follow-up were identified by deductive content analysis.

RESULTS

Focus group participants identified the following barriers to and facilitators of HRA follow up: (1) patient-level beliefs about HPV-related disease or HRA, ability to engage in care, internalised stigma and physical discomfort; (2) provider-level knowledge and expertise, communication skills and relationship-building with patient; and (3) systems-level societal stigma and healthcare system inefficiencies.

CONCLUSIONS

Reinforcing facilitators of and reducing barriers to HRA follow up may improve adherence among MSM. This includes improvements to: patient education, provider training to increase knowledge and cultural sensitivity, public awareness about HPV-related anal cancer, physical discomfort associated with HRA and systems inefficiencies.

Screening for anal cancer precursors among patients living with HIV in the absence of national guidelines: practitioners' perspectives

PURPOSE

Immunocompromised populations including people living with HIV (PLWH) suffer disproportionate burden from anal cancer, a rare cancer caused by persistent infection of the anal canal with oncogenic strains of human papillomavirus. In the US, there are no nationally adopted screening guidelines for anal cancer. In the absence of such guidelines, this study explores healthcare practitioners' screening practices for early signs of anal cancer among PLWH.

METHODS

Between November 2017 and June 2018, the research team completed 25 interviews among a diverse sample of healthcare practitioners who provide care for PLWH.

RESULTS

Providers expressed frustration that screening and treatment guidelines for anal cancer were scant, and they varied in their screening practices. The majority of providers screened PLWH for anal dysplasia via the anal Pap smear; few providers were trained and had the medical equipment to conduct high-resolution anoscopy-guided biopsies, a more sensitive and specific screening method. Others screened through digital ano-rectal examinations (DARE) and both visually and with a DARE. Participants discussed how providers may be over-treating their patients who have high-grade anal intraepithelial neoplasia (AIN) and the role of biomarkers to determine whether the lesion is carcinogenic.

CONCLUSIONS

Practitioners who provide care for PLWH are proactive in screening to help prevent and control anal cancer, a rare and slow-growing disease. Continuing to regularly surveil high-risk populations, particularly PLWH previously diagnosed with high-grade lesions, is critical to prevent and control anal cancer.

Anal cytology in women: Experience from a single tertiary center

INTRODUCTION

Anal cytology (AC) can be used as a screening tool for detection of anal HPV associated lesions, mainly in men who have sex with men and in immunosuppressed patients. Our aim is to review our experience with AC in women.

MATERIAL & METHODS

We have retrospectively reviewed all AC diagnosed between 2010-2017 in a single tertiary hospital (n = 644) and selected those performed in women (n = 158).

RESULTS

24.53% of AC were performed in women. 14.7% of all women were HIV positive and 56.7% referred anal intercourse. Squamous lesions were found in 27.2% of women, most of them ASCUS and LSIL (14% and 11.5%). HPV DNA was detected in 38.6% of patients, and 63.9% of them showed positivity for multiple high-risk types. Anal biopsy showed high grade lesions in 20% of biopsied patients. We observed a significant relationship between HPV status and receptive anal sex, and the association between HPV status and anal histological diagnosis tended to significance. Sensitivity, specificity, negative predictive value and positive predictive value for anal cytology were 57%; 83%; 28% and 94%, respectively. 70.9% of women had synchronous cervical cytology, and squamous cervical lesions were detected in 46.4% of the cases, most of them LSIL or ASCUS (21.4% and 15.2%). We did not confirm a significant association between cytological diagnosis of cervical and anal samples.

CONCLUSIONS

AC is less widely used in women than in homosexual men. However, women show important rates of anal lesions, regardless of their HIV status. More studies should be performed to assess the potential impact of screening protocols in this population.

Anal Cancer Prevention Perspectives Among Foreign-Born Latino HIV-Infected Gay and Bisexual Men

This study explores understanding of primary and secondary prevention of anal cancer among human immunodeficiency virus (HIV)-infected foreign-born Latino gay and bisexual men (GBM). Between August 2015 and December 2016, researchers conducted 33 in-depth, semi-structured interviews with HIV-infected foreign-born Latino GBM. Interview questions sought to determine participants' knowledge and perceived barriers and facilitators to primary and secondary prevention of anal cancer. Researchers analyzed interview transcripts using a qualitative content analysis approach. For primary prevention, men reported a lack of knowledge about the human papillomavirus (HPV) vaccine. However, for secondary prevention, roughly 60% of participants had previously screened for anal dysplasia via anal Papanicolaou (Pap) smear. However, participants reported willingness to screen, and provider recommendation was the most common screening facilitator. Men reported stigma related to their HIV status, sexual orientation, and anal Pap smear procedures as anal cancer screening barriers. Participants reported willingness to use a self-screening anal Pap smear test if it was commercially available. Health providers continue to be the leading source of health information. Therefore, provider recommendation for HPV vaccination and anal cancer screening among age-eligible foreign-born Latino HIV-infected GBM is critical. More work is needed to destigmatize HIV and sexual orientation to influence positive health behaviors among this population. Future intervention research could test the effects of provider-led interventions and also media campaigns aimed at influencing HPV vaccine uptake and anal cancer screening among this population.

Racial Disparities and the Effect of County Level Income on the Incidence and Survival of Young Men with Anal Cancer

Purpose: Prior studies have identified a racial disparity in incidence and survival of squamous cell carcinoma of the anus (SCCA) in the young African American male population. We aim to determine whether racial disparities are independent of income and urban location. Methods: The National Cancer Institute's Surveillance of Epidemiology and End Results database was queried for data on patients with SCCA for the years of 2000-2013. Cox regression was used to determine the effect of race, county median family income, rural-urban continuum, and stage of disease on overall survival. Results: The incidence rate of SCCA was significantly higher in black men <50 years old than in white men. Black race had a hazard ratio of 1.55 (confidence interval [CI] 1.33-1.81) when controlling for age, stage, income, and urban-rural status. Each $10,000 increase in county median family income was protective with a hazard ratio of 0.90 (CI 0.86-0.94). Residence in a metropolitan area did not significantly affect survival. Conclusions: The lower survival of black men <50 years old with SCCA is independent of income, urban location, and stage of disease. Further efforts are needed to target this at-risk population and the authors suggest wide application of previously validated screening programs for anal dysplasia.

Experience and psychological impact of anal cancer screening in gay, bisexual and other men who have sex with men: a qualitative study

OBJECTIVE

Human papillomavirus-related anal cancer rates are increasing and are particularly high in gay, bisexual and other men who have sex with men (GBM/MSM), especially HIV-positive individuals. Although screening programs for high-risk populations have been advocated, concerns about possible adverse psychological consequences exist. This study aimed to investigate GBM/MSM's experience, understanding and emotional response to screening techniques for anal cancer to determine how best to minimise psychological distress in future programs.

METHODS

In-depth qualitative face-to-face interviews were conducted with 21 GBM/MSM participating in the "Study of the Prevention of Anal Cancer" in Sydney, Australia, between June 2013 and June 2014. Nonrandom, purposive sampling was used to ensure heterogeneity with respect to HIV status and screening test results. Framework analysis method was used to organise the data and identify emerging themes.

RESULTS

Knowledge about anal cancer, human papillomavirus and the link between them was limited. Abnormal screening results affected participants' sense of well-being and were associated with anxiety and concern about developing anal cancer. HIV-negative men receiving abnormal results showed higher levels of distress compared to their HIV-positive counterparts. Consultations with general practitioners about abnormal results had an important role in increasing participants' understanding and in moderating their anxiety.

CONCLUSION

Anal cancer screening should be accompanied by health education around anal cancer, its aetiology and the meaning of associated test results. Simple and effective communication strategies should be encouraged. Collaboration with general practitioners could assist the process of education and reporting test results.