Squamous Intraepithelial Lesion of the Anus in a Man With HIV Infection

Susan C. Ball, MD, MPH


AIDS Read. 2004;14(9) 

In This Article

HIV, HPV, and Anal Cancer

Despite the prevalence of HPV and SILs among gay men, anal cancer has not been considered an AIDS-defining malignancy in patients with HIV infection in whom anal cancer develops. Cervical cancer in HIV-positive women gained this dubious honor in 1993, but anal cancer was -- and remains overall -- a relatively rare malignancy. As we have seen, MSM suffer a disproportionate share in the rising number of cases of anal cancer documented in the general population. Anal cancer is estimated to develop in MSM with AIDS at a rate that is 84 times higher than that in the general population.[16,17] HPV infection is more aggressive and more likely to recur in patients with HIV infection.[18] HPV infection and anal cancer-associated lesions are prevalent in HIV-infected persons even in the absence of anal intercourse. In a 2003 study of HIV-positive heterosexual male drug users who did not have a history of anal intercourse, 36% had an anal SIL and 46% were infected with HPV.[19]

It is difficult to separate the roles of immunosuppression and HPV infection in patients with HIV infection and SIL. It is evident, however, that the number of cases of anal cancer has continued to rise even with the introduction of HAART and the resulting overall improvement in prognosis for persons with HIV infection in the United States in the past 10 years. Epidemiologically, there are rising numbers of people living with HIV/AIDS. The death rate has been steady at approximately 15,000 per year, and there are approximately 40,000 new cases of HIV infection diagnosed annually. People living longer with HIV and HPV infections are at greater risk for the development of anal cancer. It is interesting to note that HAART has not decreased the prevalence of SIL or HPV infection among patients with HIV infection whose CD4+ cell counts have been restored.[20]

In San Diego County, a study of anal cancer incidence among AIDS patients in pre- and post-HAART periods saw a rise in anal cancer from 2.8 per 1000 AIDS cases in 1992 to 24.7 per 1000 in 2000. The investigators concluded that "the longer duration of HIV infection post-HAART suggests that HAART increases the time at risk for the development of anal cancer."[21] In the absence of a clearly defined program for the screening and treatment of SIL and HPV infection in men, it is likely that the rates of anal cancer will continue to rise. Screening HIV-infected men was clinically effective and cost-effective in a 1999 study by Goldie and colleagues,[22] but this screening has yet to become a part of the primary care or HIV specialist's routine. As the number of cases of squamous cell carcinoma of the anus increases, physician awareness will also likely increase, whereby screening for this malignancy and its precursors will improve.

In your conversation with Terry, you encouraged him to go for treatment of his SIL at the surgeon's office. You let him know that he might need further treatment if follow-up anoscopy and biopsy showed new or persistent lesions. The surgeon told him that he should come in every 3 to 6 months. Terry was not happy about this but agreed to follow the advice of his doctors. He also agreed to be more consistent with his condom use. He was relieved when, after a second treatment for an SIL, his subsequent anoscopy and biopsy results were negative.

Terry's situation has prompted you to begin performing anal PAP tests and referring patients whose results are abnormal for anoscopy and biopsy. You hope that a few cases of cancer of the anus will be averted.


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