Acceptability of High-Resolution Anoscopy for Anal Cancer Screening in HIV-infected Patients

JO Lam; GM Barnell; M Merchant; CG Ellis; MJ Silverberg


HIV Medicine. 2018;19(10):716-723. 

In This Article


EHR-based Studies

Between 2008 and 2013, 1857 HIV-infected patients underwent a first HRA at KPNC (Table 1). The mean age of patients was 50 years (range 22–86 years), 98% were men (80.7% MSM) and 67% were White. Most (93.3%) patients reported ART use and 33.5% had a prior clinical AIDS diagnosis. A pre-existing anal condition was noted in 8.8% (n = 164) of patients. Of these patients, 50.6% (83 out of 164) had an anal wart.

The initial HRA procedure was poorly tolerated in 5% (n = 95) of patients. Of these 95 patients, 94 met the prespecified definition for lack of HRA acceptability because they filled a prescription for opioid analgaesia and one patient had an ER visit (because of rectal bleeding from HRA). None of the patients required sedation for the HRA procedure. Among patients with a pre-existing anal condition, HRA was poorly tolerated in 15.2%. After adjustment for all potential predictors, lack of HRA acceptability was most likely in patients with a pre-existing anal condition at screening [adjusted odds ratio (aOR) 4.0; 95% confidence interval (CI) 2.4–6.7], those who were ever smokers (aOR 1.6; 95% CI 1.0–2.5) and women (aOR 5.3; 95% CI 1.6–17.5; Table 2). Although the number of women who had low tolerability of initial HRA was small (n = 5), they represented 13.9% of all women who were included in the study (n = 36). Lack of acceptability of HRA was not significantly associated with age, race/ethnicity, CD4 count, HIV RNA level, ART use or prior AIDS diagnosis.

Of the 997 patients with adequate follow-up time to receive a repeat HRA during the study period, half did not return for the procedure. Lack of tolerability of initial HRA did not influence likelihood of returning for a repeat HRA (aOR 0.5; 95% CI 0.3–1.1; Table 3). Only younger age was associated with not returning for a repeat HRA, with an aOR per 10–year age interval of 0.8 (95% CI 0.7–0.9). No other demographic or clinical factors were associated with likelihood of patients obtaining a repeat HRA.

Patient Experience Survey

The survey was sent to 92 HIV-positive patients, and the response rate was 53% (48 responses received; two surveys returned because of an undeliverable/wrong address). The mean age of respondents was 58 years (range 27–78 years), 98% were men (87.5% MSM) and 71% were white. All respondents had previously been prescribed ART.

Survey respondents reported that HRA-associated discomfort was greater in the days following HRA than during the procedure. On a scale of 0–10, the average levels of pain reported were 2.7 (range 0–7) during HRA, 4.3 (range 0–10) in the 2–3 days after HRA and 2.5 (range 0–9) 1 week after HRA (Table 4). Pain in the 2–3 days after the procedure was significantly greater than pain during the procedure (mean difference = 1.6; P = 0.002) but was significantly less 1 week after the procedure (mean difference = −1.7; P < 0.001). Patients < 50 years old reported the highest pain levels, compared with 50–64–year-olds and those ≥ 65 years old, and mean pain scores decreased with age for pain experienced during HRA (P–trend = 0.03), in the 2–3 days after HRA (P–trend = 0.003) and 1 week after HRA (P–trend = 0.03).

Most respondents reported that the level of pain was acceptable during HRA (91.7%), in the 2–3 days after the procedure (75.0%) and 1 week after the procedure (77.1%). Many (66.7%) respondents felt that the pain during HRA was less than they anticipated, whereas a smaller proportion felt that pain in the 2–3 days or 1 week after was less (45.8% and 47.9%, respectively). While a substantial proportion (68.8%) of patients reported bleeding after HRA, approximately half (47.9%) stated that the bleeding was less than expected and 77.1% felt that the amount of bleeding was acceptable. The amount of pain and bleeding interfered minimally with quality of life, with most patients (75.0%) reporting that they did not need to take any days off for recovery. For most patients, the pain/bleeding also did not interfere with activities such as meeting friends (79.2%), playing sports (60.4%) or going to the gym (52.1%). As recommended, 64.6% of patients abstained from receptive anal sex. Prior to their procedure, 70.8% of respondents had not heard of HRA and in most instances (77.1%), the conversation about screening was initiated by the patient's doctor. The majority of respondents (83.3%) reported that, before their first HRA, they felt little or no worry about the procedure. All survey respondents indicated they would return for another HRA if it was recommended and 72.9% reported that they would be less worried about their second HRA.