Tailored cancer screening strategies needed for people with HIV

Studies presented last week at the 20th European AIDS Conference (EACS 2025) in Paris highlighted the need for tailored cancer screening strategies in people with HIV.

The studies found that prostate cancer presents earlier and is more advanced in men with HIV and that women with a lower nadir CD4 count have greater risk of both anal and cervical cancer. A study of liver cancer screening showed that people with HIV without cirrhosis often fail to receive screening despite risk factors, while women with HIV often do not perceive themselves to be at risk of anal cancer despite a high prevalence of HPV associated with cancer among those screened.

Prostate cancer

Prostate cancer is the most commonly diagnosed cancer in men in Europe but a review of diagnosis patterns across Europe up to 2017 found big variations in rates of diagnosis, driven by national variations in testing for prostate-specific antigen (PSA). If a PSA test finds a high level of PSA for one’s age, the finding should lead to further tests for prostate cancer. However, PSA testing has limitations; not all prostate cancers are aggressive, and provided that they are monitored, such cases can be left untreated. Conversely, some men can develop prostate cancer yet show low levels of PSA when tested.  

A study of all prostate cancer diagnoses among men with HIV receiving treatment at 16 HIV clinics in Germany found 161 men who had been diagnosed with prostate cancer. Diagnosis had occurred at a median age of 61 years, compared with a median of 71 years for the German population as a whole. The baseline PSA level at diagnosis was high at 17ng/ml and in 26% the cancer had spread beyond the prostate by the time of diagnosis (metastases). Metastatic prostate cancer was significantly more likely to be diagnosed in men with CD4 counts below 500 (p=0.05).

In 59% the cancer was assessed as being at high risk of progression at the time of diagnosis. There was no difference in progression-free survival according to treatment modality (active monitoring, prostatectomy or radiotherapy) but overall survival was significantly poorer after adjusting for age, time since HIV diagnosis and CDC HIV stage in men who received radiotherapy. However, only one death was due to prostate cancer.

The German investigators recommend that PSA screening should begin at the age of 45 in men with HIV, in line with new German national guidelines for all men, with further diagnostic evaluation in cases where PSA is above 3ng/ml and re-testing within two years if PSA is in the range 1.5-3ng/ml.

Anal cancer screening in women with HIV

International guidelines recommend screening for anal cancer for women with HIV over the age of 45 but it’s unclear how often it is offered and what women think about anal cancer screening. A prospective study carried out at Padua University Hospital in Italy examined the uptake and acceptability of screening. Screening was offered to 331 women; nearly half (45%) refused, most often because they reported no history of anal sex (25%), no sexual activity for many years (12%), did not perceive themselves at risk (16%) or did not want to be screened (28%). Women were more likely to accept screening if they had been vaccinated against high-risk HPV or if they had a history of HPV-related diseases other than anal cancer.

Screening consisted of HPV DNA and pap smear testing, followed by referral for anoscopy and examination if either test was positive. Of 144 women who tested positive on either test, eight (5.9%) were subsequently diagnosed with anal cancer, and 94 of 154 tested for HPV were found to have high-risk HPV genotypes. Older age and lower nadir CD4 count were significant risk factors for anal cancer in this cohort.

Study investigator Dr Maria Mazzitelli said that to improve anal cancer screening and prevention in women with HIV, education needs to raise awareness that anal cancer risk is high regardless of history of anal sex and prioritise women at highest risk.

Cervical cancer screening

Women with HIV have a higher risk of cervical pre-cancer (cervical intraepithelial neoplasia, or CIN) and cervical cancer and guidelines recommend regular screening. However, guidelines don’t agree on how frequently screening should take place or which women should be prioritised for more frequent screening.

Researchers looked at cervical screening of women with HIV receiving treatment in the Netherlands between 2000 and 2023 to assess the factors associated with high-grade CIN. During this period, 2764 women underwent screening, which detected 246 cases of CIN2+ (incidence rate (IR)=13.5/1000 person-years, 95%CI=11.9-15.3), 121 cases of CIN3+ (IR=6.3/1000 person years, 95%CI=5.3-7.5), and two cervical carcinomas (IR=9.9/100,000 person-years, 95%CI=2.5-39.8).

A shorter period of viral suppression was also associated with a higher rate of each diagnosis, such that women who had been virally suppressed on treatment for less than two years were diagnosed with CIN2+ and CIN3+ at rates of between five and ten times those seen in women who had been virally suppressed for more than five years.

A lower nadir CD4 count (<200) was associated with a higher risk of each diagnosis, and a CD4 count below 500 around the time of screening was associated with a higher risk of CIN 2+.

To improve detection of cervical abnormalities in women with HIV, screening should prioritise younger, newly diagnosed women with a low CD4 count, and women recently virally suppressed, the researchers concluded.

Liver cancer screening

People with HIV and viral hepatitis are at higher risk of developing hepatocellular carcinoma (HCC), or liver cancer, than the rest of the population, and have poorer survival after diagnosis of HCC. In 2024, EACS recommended six-monthly screening for HCC for all people with HIV and hepatitis B co-infection who have cirrhosis or at least one risk factor (age over 45, hepatitis delta, African or Asian origin, or White with a PAGE-B score ≥10, indicating intermediate or greater risk for HCC).

Dr Juan Berenguer presented data from a multicentre study of 48 centres in Spain, Germany and Poland which assessed adherence to the screening guidelines in 1308 people with HIV and hepatitis B receiving treatment at participating clinics. Participants had a median age of 55 years, 85% were male, 35% were born outside Europe and 85% were taking regimens containing TAF or TDF. Most (83%) had undetectable HBV-DNA and half (50%) were White with a PAGE-B score ≥10.

Among these people, 1145 met the criteria for HCC screening but only 28% had been screened. Screening was much less common in people without cirrhosis (24% compared to 66% in those with cirrhosis). There was minimal difference in the likelihood of screening between different risk factors in people without cirrhosis. Screening levels in people without cirrhosis were lowest in Spain (15%) and slightly higher in Poland (28%) and Germany (35%). In those with cirrhosis, screening rates were highest in Spain (72%) and lowest in Germany (48%).