Anal HPV Infection and Abnormal Cytology in HIV-infected Women
Anal HPV Infection and Abnormal Cytology in HIV-infected Women
The population of HIV infected women seen at Boston Medical Center may have a higher
 frequency of anal cytologic and histologic abnormalities than what is reported for the
 non-HIV infected population.
BACKROUND FOR THIS STUDY Anal cancer is a growing problem in the US. The incidence of anal
 cancer has increased among both men (160%) and women (78%) from 1973 to 2000 in the US [1].
 In HIV-infected men the incidence of SCCA (squamous cell cancer of the anus) was found to
 range from 49-92 per 100,000 patient years [2]. This prompted recommendations on screening
 for anal cancer in this population. HIV-infected women are also at increased risk for
 developing anal cancer. A study based on data from AIDS and cancer registries found that the
 risk of anal cancer among women in the general population is about 1.2% and it increases up
 to 3.9% in the HIV-infected women. In addition, HIV-infected women had eight times the risk
 of in situ anal cancer compared with the number of expected cases [3].

 SCCA appears to have many similarities to cervical cancers. HPV has been detected in 88% of
 anal cancer specimens with HPV-16 found in 73% of SCCA and HPV-18 in 7% [1]. In addition,
 SCCA develops in the transformation zone between the squamous epithelium of the anus and the
 columnar epithelium of the rectum, is frequently associated with dysplasia of the anus and
 may be preceded by squamous intraepithelial changes which are also associated with HPV.

 Cervical cytology, also known as pap smear, can detect cervical cancer and its precursors.
 Countries who have adopted cervical cancer screening programs have had dramatic decreases in
 both the morbidity and mortality rates of cervical cancer.

 Anal cytology may also be used to screen for HPV associated anal lesions, and among
 HIV-infected men who have sex with men, an abnormal cytology is frequently associated with a
 dysplastic squamous cell lesion of the anus. Anal HPV infections (high risk types) have been
 found in 53 ¿ 95% of HIV-infected men. Abnormal anal cytology has been found in 41-81% of
 HIV-infected men screened with high-grade cytologic findings in 2-25% of these patients [2].

 There have been only a few studies looking at anal cytology in HIV-infected women. The
 largest study (n=235), by Holly and Palefsky [4], found that HIV positive women had a 26%
 prevalence of anal cytologic abnormalities (mostly atypical squamous cells of undetermined
 significance [ASCUS] and low grade squamous intraepithelial lesions [LSIL]). Forty-six of
 these women with abnormal cytology (60) underwent high resolution anoscopy (HRA) and 14 were
 found to have biopsy proven HSIL.

 Several risk factors for anal cytologic abnormalities in women have been suggested, such as
 positive anal HPV test, history of anal intercourse, history of cervical squamous
 intraepithelial lesions (SIL), history of vulvar warts, multifocal cervical SIL, history of
 sexually transmitted infections, more than 10 sexual partners, history of cervical, vulvar or
 vaginal cancer, immunosuppression after solid organ transplantation, HIV infection, long-term
 corticosteroids use and cigarette smoking.

 It has been suggested that all HIV-infected women, women with cervical cancer and women with
 high-grade vulvar disease or cancer should be screened for anal cytologic abnormalities.
 However, as described above there is very scanty literature describing the prevalence and
 incidence in this patient population and the largest study was conducted prior to the HAART
 era.

 We plan to estimate the prevalence and 6-12 month incidence of abnormal anal cytology with
 histologic correlates in the HIV-infected women seen at BMC. We hope that the information
 will allow us to make screening recommendations for this patient population.
Inclusion Criteria:

 -  Age 18-64 years

 -  HIV infected women

 -  due for cervical cytologic screening

 Exclusion Criteria:

 -  Pregnancy

 -  On chronic anticoagulation medication

 -  Life expectancy of the woman is less than 1 year

 -  If the woman has had a cervical or anal pap test in the last 6 months