AIDS 2014: Anal Lesions Often Resolve Without Treatment In HIV Positive Gay Men


High-grade anal dysplasia is common among gay men living with HIV, but it often resolves spontaneously and routine treatment may not be beneficial, according to results from the Australian SPANC study presented this week at the 20th International AIDS Conference in Melbourne.

Anal cancer and its precursors, anal dysplasia and neoplasia (abnormal cell growth and tissue changes), are more common among people with HIV -- especially men who have sex with men -- than in the general population. Most studies indicate that prevalence has increased in the era of effective antiretroviral therapy (ART) as HIV-positive people live longer. Yet not enough is known about how best to screen for and manage anal abnormalities in this group.

Andrew Grulich from the Kirby Institute at the University of New South Wales and fellow investigators in Sydney designed the Study of the Prevention of Anal Cancer (SPANC) to learn more about the natural history of anal human papillomavirus (HPV) infection and anal cancer precursors in HIV positive and HIV negative gay men, including incidence, clearance and risk factors.

High-risk or oncogenic types of HPV -- including HPV-16 and HPV-18 -- can cause anal, cervical, and other genital cancers. Typically people will first develop low-grade dysplasia or squamous intraepithelial lesions (LSIL), which can progress to high-grade lesions (HSIL) and eventually carcinoma. But high-risk HPV does not always cause abnormal changes, low-grade dysplasia does not always progress to high-grade lesions or cancer, and dysplasia may regress on its own without treatment.

While some experts favor routine treatment of HSIL -- which may involve chemotherapy, radiation, cauterization (burning), or surgery -- this view is controversial. HSIL is "extraordinarily prevalent" -- occurring in up to half of HIV-positive gay men -- and treatment is extremely difficult with a high rate of recurrence and adverse events, Grulich explained. "Watchful waiting" with treatment targeted only to the highest-risk cases may be a viable alternative.

SPANC is a prospective community-based study that aims to enroll 600 men by July 2015. Participants make 5 study visits over the course of 3 years. At each visit they receive anal swabs for HPV testing and cytology (examination of cell changes) as well as high-resolution anoscopy (viewing with a magnifying instrument). Men with visually apparent abnormalities undergo biopsy for histology assessment (examination of tissue changes). They are considered to have anal HSIL if they show either cytological or histological evidence of HSIL (grade 2 or 3 anal intraepithelial neoplasia).

This interim analysis included the first 450 men recruited through June 2014. All were age 35 or older, with a median age of 49 years. About 30% were HIV-positive.


"HSIL is very highly prevalent in homosexual men," the researchers concluded. However, the condition is "highly dynamic." Both prevalent and incident anal HSIL were more common among HIV positive gay men, but clearance was common regardless of HIV status.

These findings "provide a very strong justification that not all high grade anal disease requires treatment, and suggests that treatment can be targeted to people with persistent high-grade disease," Grulich said, adding that most high-grade disease noticed on a single test "will simply go away."



AE Grulich, F Jin, IM Poynten, et al. Incidence and clearance of anal high-grade squamous intraepithelial lesions (HSIL) in HIV positive and HIV negative homosexual men.20th International AIDS Conference (AIDS 2014). Melbourne, July 20-25, 2014. Abstract WEAB0102