Approximately a third of HIV-positive gay
men in Thailand developed high-grade pre-cancerous anal lesions during just one
year of follow-up, investigators report in the online edition of AIDS. Infection with high-risk strains
of human papillomavirus (HPV) was an important risk factor for the development
of high-grade lesions. The investigators were extremely concerned by their
findings and recommend that healthcare providers, policy makers and
communities of gay men will need to make plans for screening and treating
pre-cancerous anal lesions.
HIV-positive gay men are the group most
affected by anal cancer. The malignancy is preceded by anal lesions (anal
intraepithelial neoplasia, AIN), which are usually associated with infection
with high-risk strains of HPV.
Little is known about the prevalence and
incidence of high-grade precancerous anal lesions (HGAIN) among gay men in low-
and middle-income settings.
An international team of investigators
therefore designed a prospective study involving 123 HIV-positive and 123
HIV-negative gay men in Bangkok, Thailand.
They were screened for anal lesions at
baseline and again after six and twelve months. The participants also provided
samples for anal cytology to determine the prevalence and persistence of
infection with high-risk HPV strains (HPV 16/18).
The participants had a median baseline age
of 28 years. The HIV-positive participants had a median baseline CD4 cell count of
343 cells/mm3. Only 13% of HIV-infected participants were taking
antiretroviral therapy when the study started and 10% had an undetectable viral
load. At the end of the study, the proportion of HIV-positive participants taking
antiretrovirals had increased to 47%, and at the end of the study some 33% had
an undetectable viral load and median CD4 cell count was 277 cells/mm3.
Baseline prevalence of high-grade
pre-cancerous anal lesions was 19% among the men with HIV and 11% in the
During follow-up, 27% of HIV-positive men
without HGAIN at baseline had developed pre-cancerous anal lesions, as had 7%
of HIV-negative men.
The probability of having high-grade
pre-cancerous anal lesions at month twelve was 29% for HIV-positive men to 8%
for HIV-negative participants (p = 0.001).
Analysis of men with low-grade anal lesions
at baseline showed that 33% of those with HIV and 13% of HIV-negative
individuals progressed had HGAIN after twelve months of follow-up.
Anal infection with any strain of HPV was
detected in 85% of HIV-positive and 59% of HIV-negative participants (p <
HIV-positive men were significantly more
likely to be infected with a high-risk HPV strain than the HIV-negative men
(58 vs 37%, p = 0.001).
Persistent high risk HPV infection was
found in 47% of HIV-positive and 19% of HIV-negative participants.
Infection with HIV was associated with a
more than three-fold increase in the risk of developing high-grade
pre-cancerous anal lesions (HR = 3.26; 95% CI, 1.31-8.14; p = 0.011).
“MSM [men who have sex with men] with HIV
infection in our study had approximately 2-3 times higher relative risk for
incident HGAIN,” comment the authors. They believe this indicates “a role for
immunodeficiency and/or HIV-HPV interactions in the development of HGAIN”.
Persistent infection with HPV 16/18 increased
the risk of incident HGAIN by a factor of five (HR = 5.16; 95% CI, 1.89-14.08;
p < 0.001).
“The high prevalence and incidence of HGAIN
in our young MSM cohort is of great concern,” conclude the investigators, who
note that as many as 15% of men with high-grade pre-cancerous anal lesions
progress to anal cancer within three to five years. “Practitioners, policy
makers, and communities will need to plan for strategies to screen for treat
AIN using data available from their own setting.”