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Wednesday, May 10, 2006

Screening anal Pap smears and findings on high-resolution anoscopy (HRA) in the Fenway Community Health (FCH) Human Papillomavirus Clinic

Daniel E. Cohen1, Ronald Bill1, and Kenneth H. Mayer2. (1) The Fenway Institute, Fenway Community Health, Boston, MA, USA, (2) Fenway Community Health and Brown University/Miriam Hospital, 7 Haviland Street, Boston, MA, USA

Anal HPV increases anal cancer risk, regardless of HIV status. The standard of care at Fenway Community Health (FCH) now includes anal Pap smears for all men who report receptive anal sex. To date, the feasibility of routine anal Pap smears with on-site HRA has not been evaluated in a primary-care setting.

To describe FCH's experience with routine anal cytology in sexually active MSM; to evaluate the correlation between abnormalities on anal Pap smear and HRA findings among HIV-infected and uninfected patients.

Starting in 5/04, FCH patients with anal Pap results of ASCUS, LSIL or HSIL were referred for HRA in FCH's HPV Clinic. All HRAs were performed by one examiner (DEC) who biopsied lesions which were suspicious after application of acetic acid +/- Lugols iodine. Those with AIN-II/III on biopsy were referred to a local hospital-based anal dysplasia clinic for treatment.

1117 anal Pap smears were performed between 1/02-8/05, 474 in HIV-infected (HIV+) men. Overall, 453 (41%) were abnormal; in HIV+ men, 240 (51%) were abnormal. This abstract includes data on the first 153 patients for whom anal cytology was available and who underwent HRA as of 12/05; 97 were HIV+. Sixteen percent of HIV-uninfected and 32% of HIV+ patients had AIN-II/III on biopsy (p=0.03).
Among HIV+ men, 29% with ASCUS or LSIL on Pap had AIN-II/III on biopsy. Among HIV-uninfected patients, 16% had AIN-II/III. PPV of HSIL was 83%, with a specificity of 99%.

Anal cytology screening in this population yields a high number of abnormal results; a significant proportion have precancerous changes even in HIV-uninfected patients, although the prevalence of lesions was greater in HIV+ MSM.

Routine screening of MSM with anal Pap smears is feasible and acceptable to at-risk patients. Our findings confirm that even low-grade abnormalities on anal Pap smear warrant follow-up with HRA.