The human papillomavirus (HPV) is the most common sexually transmitted infection worldwide. Gay, bisexual, and other men who have sex with men (GBM) living with HIV are disproportionately impacted by ...HPV-associated anal cancer, with rates about 100-fold that of the general population. Fortunately, HPV vaccination has proven efficacy in preventing both anogenital warts (condyloma) in males and anal pre-cancers (anal intraepithelial neoplasia; AIN) in GBM up to the age of 26. We conducted in-depth, semi-structured interviews with 25 HIV-positive gay men in Toronto to gain an understanding of their knowledge and experiences related to HPV and the HPV vaccine. These participants were part of The HPV Screening and Vaccine Evaluation (HPV-SAVE) Study, and received invitations to have anal cancer screening from their primary care doctors. Interviews were analyzed following a Grounded Theory Approach. Most participants had not received the HPV vaccine. Men described a lack of prior knowledge of the health consequences of HPV for GBM living with HIV and financial barriers to vaccine access. Participants did not articulate concerns about vaccine safety. Men frequently reported initial beliefs that HPV was predominantly-or exclusively-a risk for females or young girls, and thus they had not considered the vaccine to be necessary. Some participants remained uncertain if the current availability of the vaccine, and their newly acquired knowledge of its importance, was "too little, too late" because of their age and/or HPV exposure. Improving access and uptake of HPV vaccination requires addressing both financial barriers to access as well as increasing HPV health literacy levels, particularly by reframing the long-standing gendered associations of HPV. Physicians should provide clear, tailored messages regarding HPV vaccination.
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To assess anal oncogenic human papillomavirus (HPV) and anal cytology as screening tests for detecting high-grade anal intraepithelial neoplasia (AIN 2+), as this is an immediate anal cancer ...precursor.
Cross-sectional study of 401 HIV-positive men who have sex with men (MSM). The endpoint was histologically confirmed AIN 2+ obtained by high-resolution anoscopy. Cytology and biopsy specimens were assigned random numbers and independently assessed by two pathologists.
We did concomitant anal cytology, anal HPV testing and HRA with directed biopsies without knowing the results of each intervention. The main outcome measures were the sensitivity, specificity, negative predictive value and positive predictive value of anal cytology and oncogenic HPV for the detection of AIN 2+.
Cytology was abnormal in 67% of patients: high-grade squamous intraepithelial lesion, 12%; low-grade squamous intraepithelial lesion, 43% and atypical squamous cells of undetermined significance, 12%. Biopsies were abnormal in 68% of patients: AIN 2+, 25% and AIN 1, 43%. HPV was detected in 93% with multiple HPV types in 92% and oncogenic HPV types in 88%. Test performance characteristics for the detection of AIN 2+ using any abnormality on anal cytology were: sensitivity 84%, specificity 39%, negative predictive value 88% and positive predictive value 31%; using oncogenic HPV: sensitivity 100%, specificity 16%, negative predictive value 100% and positive predictive value 28%.
Anal cytology and HPV detection have high sensitivity but low specificity for detecting AIN 2+. HIV-positive men who have sex with men have a high prevalence of AIN 2+ and require high-resolution anoscopy for optimal detection of high-grade anal dysplasia.
The quadrivalent HPV vaccine (types 6, 11, 16 and 18) protects against high-grade cervical lesions47,48 and against high-grade anal dysplasia among men who have sex with men.49 Rates of high-grade ...dysplasia related to the types of HPV against which the vaccine protects were reduced by 54.2% (95% CI 18.0-75.3) in the intention- totreat population and by 74.9% (95% CI 8.8-95.4) in the per-protocol population.49 The vaccine also reduced persistent anal infection. In addition to its role in preventing cervical cancer among women, the quadrivalent HPV vaccine is recommended in Canada for boys and men between the ages of 9 and 26 years for the prevention of AIN grades 1-3, anal cancer and anogenital warts.9 The bivalent vaccine (types 16 and 18) has been proven to help protect against high-grade cervical lesions; however, there have been no randomized controlled trials looking at the bivalent vaccine in preventing high-grade anal dysplasia. We performed a PubMed and Embase literature search from the earliest possible date to June 2014. We used the search terms "anal cancer" and "anal intraepithelial neoplasia" with the following medical subject headings to identify the most relevant research: "HIV," "incidence," "HPV," "HPV vaccine," "treatment," "HAART," "cART," "trends," "cigarette smoking," and "solid organ transplantation." We manually reviewed the abstracts and bibliographies of relevant studies to identify additional articles. We included all types of reports (randomized controlled trials, meta-analyses, reviews and prospective cohort, retrospective cohort, case- control and cross-sectional studies). We included only articles in English. Where possible, we selected the most recent articles (published within the last 5 yr) with the highest level of evidence (e.g., randomized controlled trials; meta-analysis of randomized controlled trials) for inclusion. We reviewed 232 articles for relevance, 49 of which are included in this review.
Implementation of anal cancer screening requires the procedure to be acceptable to the target population. Our objective was to assess the beliefs of men living with HIV regarding anal cancer ...screening and identify factors associated with their willingness to participate in screening.
We developed a cross-sectional questionnaire using the Theory of Planned Behavior to examine beliefs regarding prevention of human papillomavirus (HPV)-related diseases, administered to men living with HIV in 2016-2017 in a multi-site HIV clinical cohort. Correspondence analysis was used to examine the interrelationships between men's beliefs and willingness to undergo anal cancer screening. We used multivariable proportional odds models to identify factors associated with increasing willingness. Results were reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI).
Among 1677 male participants, the vast majority (90%) would be willing to undergo screening by "anal Pap test"; willingness clustered with positive beliefs (e.g. confident they can get screened; disagree that they will feel pain) in the correspondence analysis. Higher self-perceived risk for anal cancer and positive beliefs regarding screening were associated with higher willingness to be screened. Gay, bisexual and other men who have sex with men had higher willingness (aOR = 1.62; 95% CI: 1.15, 2.29) than heterosexual men. Racialized men reported lower willingness (aOR = 0.68; 95% CI: 0.54, 0.89) than white men.
Men generally had positive beliefs and were willing to undergo screening, though there were differences by sexual orientation and racial identity. Tailored community-led initiatives could focus on men's understanding of their risk and expectations of anal cancer screening to facilitate participation.
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The human papillomavirus (HPV) is the most common sexually transmitted infection (STI) worldwide. Gay, bisexual, and other men who have sex with men (GBM), and GBM living with HIV in particular, are ...disproportionately impacted by HPV-associated cancers. The HPV vaccine, given early enough in life, may markedly reduce the likelihood of such cancers. In Canada, most provincial insurance programs only cover HPV vaccination for GBM up to the age of 26. Our objective was to understand physicians' everyday experiences and challenges in recommending HPV vaccination to older GBM patients.
As part of the HPV Screening and Vaccine Evaluation (HPV-SAVE) Study, we conducted semi-structured interviews with 25 HIV-positive GBM patients who had received anal cancer screening and 15 service providers, including 13 physicians, who had arranged for anal cancer screening in the Canadian provinces of Ontario and British Columbia. In this analysis, we draw upon the 13 physician interviews, which were coded following Grounded Theory.
Physicians strongly supported the HPV vaccine for all GBM and considered it to be important for the management of HIV-related care. However, the overall support for HPV vaccination among physicians did not translate into consistent recommendation practices. There were two overarching factors that limited the strength/frequency of physicians' vaccine recommendation practices. First, cost/insurance coverage for some older patients impacted if and how the HPV vaccine was discussed. Second, physicians had diverse perspectives on both the prevention and therapeutic benefits of vaccinating older GBM and the reality that national guidelines are incongruent with publicly funded vaccine programs for vaccinating patients over 26 years old. These two interrelated factors have co-produced an apparent economic-evidentiary conundrum for many physicians regarding how and for whom to offer HPV vaccination.
Economic barriers coupled with evidentiary and guideline gaps have created clinical practice challenges for physicians and has resulted in different messages being communicated to some older GBM patients about how important HPV vaccination is for their health.
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BACKGROUND:High-grade intraepithelial neoplasia is known to progress to invasive squamous-cell carcinoma of the anus. There are limited reports on the rate of progression from high-grade ...intraepithelial neoplasia to anal cancer in HIV-positive men who have sex with men.
OBJECTIVES:The purpose of this study was to describe in HIV-positive men who have sex with men with perianal high-grade intraepithelial neoplasia the rate of progression to anal cancer and the factors associated with that progression.
DESIGN:This was a prospective cohort study.
SETTINGS:The study was conducted at an outpatient clinic at a tertiary care center in Toronto.
PATIENTS:Thirty-eight patients with perianal high-grade anal intraepithelial neoplasia were identified among 550 HIV-positive men who have sex with men.
INTERVENTION:All of the patients had high-resolution anoscopy for symptoms, screening, or surveillance with follow-up monitoring/treatment.
MAIN OUTCOME MEASURES:We measured the incidence of anal cancer per 100 person-years of follow-up.
RESULTS:Seven (of 38) patients (18.4%) with perianal high-grade intraepithelial neoplasia developed anal cancer. The rate of progression was 6.9 (95% CI, 2.8–14.2) cases of anal cancer per 100 person-years of follow-up. A diagnosis of AIDS, previously treated anal cancer, and loss of integrity of the lesion were associated with progression. Anal bleeding was more than twice as common in patients who progressed to anal cancer.
LIMITATIONS:There was the potential for selection bias and patients were offered treatment, which may have affected incidence estimates.
CONCLUSIONS:HIV-positive men who have sex with men should be monitored for perianal high-grade intraepithelial neoplasia. Those with high-risk features for the development of anal cancer may need more aggressive therapy.
Background. Transmission of Entamoeba histolytica generally occurs by fecal excretion of cysts followed by oral ingestion of contaminated food or water. However, fecal-oral transmission may occur ...within households and long-term care institutions, and sexual transmission occurs among men who have sex with men. Epidemiologically linked clusters of E. histolytica infection are rare in industrialized countries. We report such a sexually linked cluster in Canada. Methods. An index case involving a young female with an amebic liver abscess led to an epidemiological investigation of sexual contacts. Anti-amebic serological analysis, stool specimen examinations, and abdominal ultrasounds were done for the contacts. Enzyme-linked immunosorbent assay was done for stool antigen specific to E. histolytica. Genotyping and phylogenetic analysis was performed on 1 stool isolate. Results. By tracing sexual contacts related to the index case, we uncovered a cluster of 7 cases of amebiasis (3 with liver abscesses). Oral-anal sex was common in the group; the 5 female individuals were bisexual (4) or homosexual (1). The outbreak strain was genotyped, and cluster analysis indicated that this virulent strain differed substantially from asymptomatic or diarrheal E. histolytica isolates. Conclusions. E. histolytica can be transmitted by heterosexual activity as well as male and female homosexual activity. Patients with amebiasis should be counselled about possible sexual transmission.
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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% CI0.29 to 0.80) or to have been screened by DARE (aOR = 0.27; 95% CI0.17 to 0.44) or anal cytology/anoscopy (aOR = 0.51; 95% CI0.31 to 0.83), and African, Caribbean, or black men (aOR = 0.47; 95% CI0.31 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.
Targeted screening programs for patients at high risk for anal squamous-cell carcinoma have been proposed; however, the evidence in support of screening remains unclear.
This study aimed to determine ...whether screening high-risk patients (predominantly those living with HIV) detected squamous-cell carcinoma at an earlier stage compared to the routine practice of not screening.
This is a cohort study.
This study was conducted at a quaternary care center in Canada.
Included patients were at least 18 years old with a pathologic diagnosis of invasive anal squamous-cell carcinoma between 2002 and 2022.
Patients diagnosed through a high-risk screening program were compared to those who did not undergo screening.
The primary outcome was clinical stage at presentation, categorized as T1N0M0 vs other. Secondary outcomes included treatments received, treatment failure, and overall survival.
A total of 612 patients with anal squamous-cell carcinoma were included, with 26 of those patients diagnosed through a screening program. Patients with screen-detected cancers had greater odds of presenting with T1N0M0 tumors compared to unscreened patients (18 69.2% vs 84 14.3%; adjusted OR 9.95; 95% CI, 3.95-25.08). A propensity score-matched sensitivity analysis found similar results (OR 11.13; 95% CI, 4.67-26.52). Screened patients had greater odds of treatment with wide local excision alone, as opposed to any combination of chemotherapy, radiation therapy, and surgery (3 12.5% vs 18 3.2%; OR 4.38; 95% CI, 1.20-16.04). There were no statistically significant differences in treatment failure or overall survival between groups.
The small number of screened patients limits the power of the analysis.
Screening for anal squamous-cell carcinoma among high-risk populations detects cancers at an earlier stage. Patients with screen-detected cancers also had a greater likelihood of being candidates for wide local excision alone, which may have spared them the morbidity associated with chemoradiotherapy or abdominoperineal resection. See Video Abstract.
ANTECEDENTES:Se han propuesto programas de cribado dirigidos a pacientes con alto riesgo de carcinoma anal de células escamosas; sin embargo, la evidencia a favor de la detección sigue sin estar clara.OBJETIVO:Este estudio tuvo como objetivo determinar si el cribado de pacientes de alto riesgo (predominantemente aquellos que viven con el VIH) detectó el carcinoma de células escamosas en una etapa más temprana en comparación con la práctica habitual de no cribado.DISEÑO:Este es un estudio de cohortes.CONFIGURACIÓN:Este estudio se realizó en un centro de atención cuaternaria en Canadá.PACIENTES:Los pacientes incluidos tenían al menos 18 años con un diagnóstico patológico de carcinoma de células escamosas anal invasivo entre 2002 y 2022.INTERVENCIONES:Los pacientes diagnosticados mediante un programa de cribado de alto riesgo se compararon con aquellos que no se sometieron a cribado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el estadio clínico en la presentación, categorizado como T1N0M0 versus otro. Los resultados secundarios incluyeron los tratamientos recibidos, el fracaso del tratamiento y la supervivencia general.RESULTADOS:Se incluyeron un total de 612 pacientes con carcinoma anal de células escamosas, con 26 de esos pacientes diagnosticados a través de un programa de cribado. Los pacientes con cánceres detectados mediante cribado tenían mayores probabilidades de presentar tumores T1N0M0 en comparación con los pacientes no cribados (18 69.2% frente a 84 14.3%; razón de probabilidad ajustada 9.95; intervalo de confianza del 95 % 3.95 -25.08). Un análisis de sensibilidad emparejado por puntaje de propensión encontró resultados similares (odds ratio 11.13; intervalo de confianza del 95% 4.67 -26.52; p < 0.001). Los pacientes examinados tenían mayores probabilidades de recibir tratamiento con escisión local amplia sola, en comparación con cualquier combinación de quimioterapia, radiación y cirugía (3 12.5% frente a 18 3.2%; razón de probabilidad 4.38; intervalo de confianza del 95 % 1.20 -16.04). No hubo diferencias estadísticamente significativas en el fracaso del tratamiento o la supervivencia global entre los grupos.LIMITACIONES:El pequeño número de pacientes evaluados limita el poder del análisis.CONCLUSIONES:La detección del carcinoma anal de células escamosas entre las poblaciones de alto riesgo detecta los cánceres en una etapa más temprana. Los pacientes con cánceres detectados mediante cribado también tenían una mayor probabilidad de ser candidatos para una escisión local amplia sola, lo que puede haberles evitado la morbilidad asociada con la quimiorradioterapia o la resección abdominoperineal. (Traducción --Dr. Aurian Garcia Gonzalez ).
Background
High‐risk human papillomavirus (HPV) has been identified in the pathogenesis of anal cancer. The purpose of this study was to assess the prevalence of abnormal anal cytology and HPV in ...women aged ≥40 years who have a history of high‐grade cervical squamous intraepithelial lesion (SIL) or cancer and to estimate the prevalence of anal intraepithelial neoplasia (AIN) using cytology as the primary screening modality.
Methods
Women who had a history of high‐grade cervical SIL or cancer and were ≥40 years of age were included in this prospective study. Anal cytology with HPV‐DNA testing was performed. All patients with abnormal anal cytology were referred for high‐resolution anoscopy (HRA), and abnormal lesions were biopsied and treated if pathologically confirmed. Abnormal anal cytology correlated with HPV status, HRA findings, and clinical and demographic characteristics.
Results
A total of 317 women completed the study. Of these, 96 (30.3%) had abnormal anal cytology (high‐grade SIL, 12.5%; low‐grade SIL, 19.8%; atypical squamous cells, cannot exclude high‐grade SIL, 6.3%; atypical squamous cells of undetermined significance, 61.5%) and 101 (31.9%) were HPV‐DNA–positive. There was a significant association between abnormal cytology results and the presence of high‐risk HPV. Of the 96 patients with abnormal cytology, 30 (31.3%) had biopsy‐proven AIN on HRA, representing 9.5% of the total patient cohort; of these, 10 (33.3%) had low‐grade AIN and 20 (66.7%) had high‐grade AIN. Older age and smoking were significant risk factors for abnormal anal cytology.
Conclusion
Women aged ≥40 years with a history of high‐grade cervical SIL or cancer have a high rate of AIN. Screening for anal cancer may therefore be considered in this patient population. The optimal screening approach should be addressed in future studies.
Almost one‐third of women with a history of cervical high‐grade squamous intraepithelial lesion and cervical cancer have abnormal anal cytology. Of these, 30% have biopsy‐proven anal intraepithelial neoplasia.
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