Women living with HIV had a higher risk of anal
pre-cancerous changes than cervical changes linked to human papillomavirus (HPV),
French researchers reported at the 14th European AIDS Conference in
Brussels. They suggested that all women with HIV ought to be screened routinely
for pre-cancerous changes in the anal canal.
The study also found that there was no association between
pre-cancerous changes in the anal canal and a prior history of anal
intercourse, but a strong association with a previous history of cervical
Clinical management guidelines for women with HIV recommend
routine screening for pre-cancerous cervical changes according to national
guidelines. There is no consensus regarding anal screening in women with HIV.
French researchers carried out a study to determine the
prevalence of anal HPV infection and pre-cancerous changes in the anus among
women with HIV participating in a national cohort study. The study recruited
319 women who agreed to anal HPV screening, of whom 171 (54% of the cohort)
consented to an anal examination by a proctologist. Women who declined to take
part in the anal examination had significantly higher CD4 counts, a longer
duration of HIV infection and a higher frequency of viral suppression on
antiretroviral treatment (98% of all participants were taking antiretroviral
The median age of women who took part in the study was 47
years, the median CD4 cell count 655 cells/mm3 and 36% were from sub-Saharan
Africa. Thirty-six per cent of the women reported a prior history of receptive anal
Women underwent cervical PAP and HPV testing and anal
cytology and HPV testing. High-resolution anoscopy was performed in order to
identify the stage of any lesions in the anal canal.
Anoscopy diagnosed anal lesions in 34% of women (21 of 171
samples were excluded due to unsatisfactory sampling). Low-grade (AIN-1)
lesions were diagnosed in 21% of women and high grade (AIN 2-3) intraepithelial
neoplasia in 13% of women. One woman was diagnosed with anal cancer. A high
prevalence of HPV types associated with cancer was detected (57%). Two-thirds
of women with high-risk HPV sub-types had more than one high-risk sub-type.
The sensitivity of high-resolution anoscopy to detect
high-grade anal intraepithelial neoplasia was 76% and the specificity 61%.
By multivariate analysis high-grade anal intraepithelial
neoplasia (HGAIN) was associated with a history of cervical low-grade
intraepithelial lesions (relative risk 4.0, 95% confidence interval 1.0-15.8,
p = 0.05). HGAIN was more strongly associated with the detection of HPV-16
(relative risk 15.6, 95% confidence interval 5.2-46.8, p<0.0001).
In a comparison of cervical and anal cytology and HPV
testing results, both low-grade lesions and high-risk HPV types were found to
be more common in the anal canal.
This study was cross-sectional in design, and so evaluated
only the prevalence of HPV-associated lesions and high-risk HPV types. The
tendency of low-grade cervical lesions to regress during follow-up has led to
uncertainty regarding the natural history of HPV-related anal lesions, so a
prospective study which followed women for several years might lead to
different estimates of risk. Nevertheless, the French research group concluded
that their findings suggest that anal HPV screening may be warranted in all
women with HIV.