Anal cancer screening in a cohort of women with HIV: Uptake and outcomes from a prospective study in Northern Italy

IntroductionWomen with HIV face a significantly elevated risk of developing anal cancer (AC). However, data about screening (S) implementation in clinical practice and women's acceptability are still scarce.MethodsSince October 2022 our clinic implemented anal cancer screening (ACS) using anal HPV-DNA/cytology for women with HIV. Women with at least one positive result from these tests were referred for a high-resolution anoscopy (HRA). We collected demographic and clinical data, ACS adherence rates and reasons for refusal. Multivariable analyses were conducted to identify factors associated with ACS refusal and the presence of high-risk human papilloma virus (HPV) genotypes, HSIL and AC.ResultsACS was offered to 331 women with HIV, but 150 (45.3%) refused testing: main reasons for refusal included lack of specific concerns, no history of anal sex and a perception of not being at risk of having AC. One hundredmeightyone women underwent ACS. Cytology and HPV-DNA were positive in 54 (29.8%) and 139 (76.8%) cases. High-risk HPV genotypes were detected in 94 (67.6%) women with HIV. HSIL, LSIL and ASC-US were detected in 8 (4.4%), 43 (23.7%) and 3 (1.6%) women with HIV, respectively. Of the 135 women (93.7%) who underwent HRA, 19 (14.1%) had lesions requiring biopsies: 6 were negative, 5 were positive for dysplastic polyps, and 8 (5.5%) were diagnosed with AC. Older age, lower nadir CD4 counts, and a previous history of cervical HPV-related disease were significant risk factors for HSIL and AC. Conversely, partial or complete HPV vaccination were protective factors against high-risk HPV infection.ConclusionsDespite the high prevalence of anal HR-HPV genotypes and the high risk of AC among women with HIV, the uptake of ACS in our cohort was notably low. Among those who participated, a high prevalence of HPV infection and associated cytological abnormalities was observed, indicating an urgent need for increased awareness and education regarding AC in this population. The findings identify crucial risk factors, such as older age and lower CD4 counts, while also suggesting that HPV vaccination may offer protective benefits against high-risk HPV infections. These insights emphasize the importance of targeted screening programmes and interventions to improve health outcomes for women with HIV.