Seville Cohort of People Living With HIV at Risk for Anal Cancer
Seville Cohort of People Living With HIV at Risk for Anal Cancer
There is increasing awareness of augmenting risk of anal cancer in people living with HIV,
 especially among men who have sex with men (MSM). High resolution anoscopy (HRA) represents
 the gold standard to detect pre-cancerous anal high-grade squamous intraepithelial lesions
 (HSIL), however, the procedure is time-consuming, costly and, most importantly, the learning
 curve is very flat. This yields a poor implementation of anal screening and, likely, to an
 excess of otherwise preventable anal cancer. Other screening methods include digital
 ano-rectal examination, anal-rectal cytology and human papillomavirus (HPV) genotyping, since
 infection with high-risk HPV genotypes has been identified as the main reason for the
 development of HSIL. To date, there is no consensus in screening strategies. Furthermore, it
 remains unclear whether, in whom and to which extend the currently available topic and
 invasive treatment options for HSIL should be applied, given that the natural history of the
 development of anal cancer remains poorly understood. The present cohort study aims to
 provide real-life data on the screening, management and follow-up of HIV-infected MSM is
 warranted for a better understanding of anal cancer in this setting.
The development of anal precancerous squamous intraepithelial lesions (SIL) and cancer of the
 anus is mainly caused by infection with high-risk human papillomavirus genotypes (HR-HPV).
 There is increasing awareness of marked (40 to 130-fold) risk of anal cancer in people living
 with HIV, especially among men who have sex with men (MSM). With the changing scenario of
 comorbidities in the HIV-infected population, given the success of modern antiretroviral
 therapy, anal cancer has emerged as a leading neoplasia across different cohorts in Western
 countries. iIn 2014, almost 30000 people were newly diagnosed with HIV in Europe, the
 majority of cases (77%) being men. This was largely driven by HIV transmission between MSM,
 which accounted for 42% of all HIV diagnoses. Hence, the incidence of anal cancer is likely
 to increase in the years to come.

 The number of experts who support the necessity of implementing wide programs of anal cancer
 screening in at-risk populations is rapidly growing. Indeed, both the European Guidelines for
 treatment of HIV-infected adults and the Guidelines of the Spanish AIDS Society (GESIDA)
 currently recommend the screening of anal cancer in HIV-infected subjects at risk. It is
 likely that in years to come, a general recommendation to screen for anal cancer in patients
 with different conditions associated with immunosuppression is established, as experienced in
 other populations. In this context, since HIV-negative MSM and women with a history of
 anogenital dysplasia, as well as transplant patients, exhibit excess risk of anal cancer,
 these populations have been typically screened in center with ongoing anal cancer screening
 programs.

 Digital ano-rectal examination (DARE) is mainly accepted as the first screening procedure for
 anal high-risk SIL (HSIL), followed by anal-rectal cytology. Both represent simple methods,
 however, cytology shows an alarmingly low negative predictive value and furthermore, in case
 of an abnormal cytology, the patient is referred to high resolution anoscopy (HRA) for biopsy
 of acetowhite lugol-negative lesions in the anal epithelium, suggestive of HSIL. HRA
 performance is similar to cervical colposcopy, but unfortunately, the training process is by
 far longer, hampering its implementation and availability to highly-specialized centers with
 large cohorts of people living with HIV under care.

 Although histological HSIL was identified as precursor of anal cancer, it remains unclear if,
 which and in whom treatment is indicated, since not all patients progress, a considerable
 proportion even regresses spontaneously and recurrence rates are high. Treatments currently
 available include topical imiquimod or 5-fluorouracil, as well as surgical treatment. Due to
 the lack of data, no consensus of HSIL management has been reached.

 Taken together what was mentioned above, real-life data on the screening, management and
 follow-up of HIV-infected MSM is warranted for a better understanding of anal cancer in this
 setting.
Inclusion Criteria:

 -  HIV infection as confirmed by ELISA and western blot

 Exclusion Criteria:

 -  Unable to provide informed consent