ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

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Robert Zangerle (Austrian Society of Dermatology and Venereology) found thatanal cancer is 300x more common in HIV+ MSM in Austria. He studied the extensive database of the HIV cohort  2003-2015 where he identified invasive anal Ca in 47/7500 patients; of these, 7 died of their cancer and 4 of AIDS related illness. There was no information available on sexual habits and HPV vaccination rates (assumed to be very low.)

 

Carmen Hidalgo-Tenorio (Infectious Disease Unit, University Hospital Virgen de las Nieves, Granada, Spain) looked at HSIL in HIV +ve women in Spain. Of the 95 women,  28.4% had had anal intercourse. Anal cytology was normal in 46%, 22.1% were positive for HPV with a negative smear, and 13% were  atypical. She found HSIL IN 16/100,000. Significant predictors for HSIL were number of sexual partners >3 and abnormal cytology. Interestingly atypical anal cytology was commoner than cervical in HIV positive women.

 

Alessandra Vergori (Rome, Italy) reminded us that PLWH have 15-25 x rate for  anal ca and 2.1 x that for oral. She studied 395 HIV +ve men. 96% were on ART, 47% were smokers. The average number of sexual partners were 100 for MSM and 12% in heterosexual men. HPV was present in 20% oral, 83% anal testing and 50% of anoscopy samples showed atypia. Significant associations were the number of sexual partners and a low CD4 count.

 

Deborah Konopnicki (Centre Hospitalier Universitaire Saint-Pierre, Brussels) gavethe stark statistic that the mortality rate for invasive anal Ca is 31%. Screening for anal and oral HPV is difficult and a more practical approach is vaccination. HPV vaccines are virus-like particles and completely non- infectious. 9vHPV is now available covering serotypes 16/18/31/33/45/52/58/6/11. Good AB levels persist for at least 12 yrs following vaccination. Vaccination has been proved to be safe and effective in HIV+ Patients but vaccination is much more effective in everyone when given before significant HPV exposure ie. in early teens. EACS recommendations are to vaccinate all women up to age 26y and all MSM to 40y if HIV +ve or 26 if -ve

Vaccination reduces relapses in treated HPV by 65% in women and 50% in men.

It has been shown that if vaccinated under 15yrs, 2 doses and probably 1 dose are as effective as the triple dose regime. The consensus appears to be that single dose vaccination will be recommended in primary vaccination of teens but 3 doses are still required in HIV patients.

 

 

Day 3 – Joint Symposium Session: Prevention of Anal Cancer in gay and Bisexual Men: The Current State-of-Play and Future Directions.

“What should we be doing for our patients now?”  Dr Jason Ong, Monash University, The Alfred – Melbourne Sexual Health Centre, VIC, Australia

Dr Ong acknowledged the HPV vaccine as a game-changer in the prevention of HPV-associated anal cancer however there is still a cohort of males who remain unvaccinated and therefore will continue to be at risk of anal cancer for many years to come.

Many ask the question: if screening for cervical cancer using the PAP smear works so well in early detection of cervical pre-cancerous lesions, then why can’t we take this methodology and apply it to anal screening of MSM for pre-cancerous lesions (aka ‘CHAP smears’)?

Some similarities and differences between anal and cervical anatomy and lesions were described:

Similarities:

-       Both have transformational zones

-       HPV responsible for a significant proportion of pre-cancerous changes

-       Pre-cancerous lesions are histologically similar

Differences:

-       The anal canal is a much larger area to swab (approx. 5cm tube)

-       It is more difficult to visualise anal lesions

-       Natural history of lesions between each site is different (up to 30% of anal smears are positive for abnormal changes)

-       Progression of changes is different as many more anal intraepithelial neoplasia (AIN) resolve over time compared to cervical intraepithelial neoplasia (CIN)

-       Different referral rates (only approx. 3% of cervical PAP smear result in onward referral for colposcopy but up to 60% of men undergoing anal screening would need referral due to the increased rate of high grade anal lesions.  This has implications for the workforce as it does not have the capacity to deal with such a large volume of referral for anoscopy or further investigation). 

High-grade anal intraepithelial neoplasia (HGAIN) regress at a rate of 36/100 person years so if left alone, many would disappear.

In answering the question of whether we should screen for early anal cancer, Dr Ong explained that the best annual screening tool for MSM would be the digital anorectal examination (DARE).  As approx. 50% of anal cancers are externally visible and approx. 2.9cm in size, and due to the fact that many HGAIN resolve spontaneously over time without intervention, DARE is a most cost-effective and simple early detection technique.

In another study, Dr Ong also explored the acceptability of a DARE for men with favourable findings.  82% of men felt relaxed during the procedure and 99% were willing to have another DARE in a years time.

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As a side note, Dr Ong will be conducting a teaching session on Friday 16th Nov from 10:30am-11:00am using his plastic bum segment for this wishing to perfect their DARE technique …sadly I will miss out!

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

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