Human papillomavirus-associated anal squamous intraepithelial lesions in men who have sex with men and transgender women living with and without HIV in Karachi Pakistan: implications for screening and prevention

Background Anal squamous intraepithelial lesions (ASIL), strongly related to human papilloma virus (HPV) infection, is more prevalent among men who have sex with men (MSM). However, no such data are available for Pakistan yet, and neither HPV vaccination nor anal-cytology screening is implemented in Pakistan. The purpose of this first ever study was to assess the prevalence of HPV-related anal cytological abnormalities among MSM and transgender women living with and without HIV infection in Pakistan. Methods We conducted a cross-sectional study from March 2016 to November 2017 at sexual health centers run by the Perwaaz Trust and the National AIDS Control Program in Karachi. The study enrolled MSM and transgender women aged greater-than-and-equal-to-18-years who reported anal sex in the preceding 6 months. We collected two anal samples for liquid-based cytology and HPV type testing by PCR, and socio-demographic and behavioral data were collected through face-to face interviews. ASIL and its associations with biological and behavioral risk factors were analyzed through Cox regression for prevalence ratios (PR) and corresponding 95% confidence intervals (CIs). Results Out of 271 qualifying participants, 79% were MSM and 21% transgender women. The mean age was 28.8 (± 8) years. Almost 35% (93/271) of the study population had ASIL detected, ASIL was significantly more common among participants living with HIV than in HIV negative ((50/118) 42.4%; vs. (43/153) 28.1%) (p ≤ 0.001). Among ASIL, 66% (61/93) had low-grade squamous intraepithelial lesions (LSIL), and 3.6% (3/93) had high-grade squamous intraepithelial lesions (HSIL). The overall, HPV16 positivity was 35.5% (33/93) among all abnormal anal lesions and all 3 HSIL were HPV16 positive, however, HPV16 positivity could show its association with ASIL detection in univariate model only (PRcrude: 2.11(1.39–3.18)). Moreover, any HR-HPV type (PR 3.04; 95% CI 1.75–5.26), concurrent sexually transmitted infection (STI) (2.13; (1.28–3.55)) and HIV + /HPV + coinfection (1.75; (1.07–2.88)) remained independently associated with ASIL in the multivariate model. Conclusions Abnormal anal cytology among MSM and transgender is prevalent enough to consider optimal screening regimens. Further studies are required to see if periodic anal cytology can be made part of HIV care and treatment programs among MSM in Pakistan.

Reactive Cellular Changes in Anal Cytology Smears and Its Relation to Future Dysplastic Changes in HIV+ Subjects

Introduction/Objective The incidence of anal squamous cell carcinoma is increasing in high risk populations. There is no consensus regarding screening for anal squamous cell carcinoma. Anal pap smears are interpreted using the Bethesda System for cervical cytology. Significant challenges exist for anal cytology that do not apply to cervicovaginal cytology. Methods/Case Report We retrospectively reviewed the anal cytology smears performed in our institution between 2012- 2019. The smears with reactive cytology changes (RCCs) were retrieved, and corresponding follow up smears were reviewed. Results (if a Case Study enter NA) A total of 39 cytology smears with positive RCCs with no dysplasia diagnosis were obtained. All were HIV+. 32 cases were male and 7 females. The overall mean age was: 37.77 + 11.94 SD (range: 23-65 years). The mean age for men was 36.53 + 11.51 and 43.43 + 13.13 for women. Although this mean age was higher for women, the age difference was statistically insignificant (p=0.7, alpha=0.05). Four of the women patients had concomitant cervicovaginal cytology all of which were negative. Only 1 female had a follow up study which was negative. Of the 39 cases, 26 cases (25 men and 1 woman or a total of 66.7%) had followed up smears versus 13 (33.3%) cases with no follow up. A total of 7 out of the 26 follow ups were negative for dysplasia (26.92%). Of the 26 follow ups, a total of 18 (69.23%) were found to have progressed to either ASCUS (15 or 57.69%) or LSIL (3 or 11.53%). One ASCUS was diagnosed as possible high grade. The mean time to convert to dysplasia was 2.06 + 1.25 years (range 1-5 years). Half of the dysplastic cases developed in a 1 year period. Conclusion Patients who have reactive changes on anal cytology should be monitored for possible development of anal neoplasia.