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Negative HRA but positive anal pap smear

Mar 1, 2012

Hi Nelson,

First of all, I have nothing but respect for you and the way you offer your time and expertise despite living with multi-drug resistant HIV and the stress that must engender. Recently I had a HRA (high resolution anoscopy) examination (I am positive, undetectable 3.5 years, positive 4 years, cd4 330) and the examination didn't reveal any abnormalities, so I was relieved at that. When the pap smear results came back indicating AIN2 I was a quite shocked. A previous smear test 15 months ago revealed nothing out the ordinary. Should I be worried? How do you interpret these results? If I have HPV infection, how long will it take someone like me with a lowish cd4 count to get rid of it? I am in a long term exclusive relationship with a neg guy so hopefully re-infection of HPV shouldn't be a problem? We continue to use protection. Thanks. M. ps, I have read your previous responses to anal cancer issues but couldn't find an answer to this question.

Response from Mr. Vergel

The fact that you have not been HIV positive for too long and that you have a clean high resolution anoscopy are good things when it comes to feeling more relaxed about your chances of having anal dysplasia (changes in the anal canal mucosa that can lead to cancer).

As you know, an anal canal examination can be done in several ways. A digital exam is when the doctor places a gloved finger in the anal canal to feel for lumps. But this method can only detect warts and hemorrhoids, or really advanced anal cancer. Anoscopy is a visual examination of the anal canal mucosa using an anoscope with a bright light. Lastly, there is a special kind of anoscopy called high-resolution anoscopy (HRA), which uses a magnifier to provide more detailed images of the mucosa. During the procedure, lesions are enhanced by first applying a thin layer of dilute vinegar to the mucosa. HRA is not widely available in all clinics, specially in those funded by Ryan White and other public funding.

Dysplasia can be diagnosed in the anal canal with a Pap smear similar to that used to detect cervical cancer in women. Cells collected from a swab inserted in the anus are examined under a microscope for pre-cancerous changes.

Pap smears can be useful if there is no access to HRA, but they can produce "false negative" results. In other words, the lab may report a test result as "normal" when there really is dysplasia found in the anal canal by HRA. The Pap smear can also give a "false positive"the lab reports dysplasia, but none is found on HRA. That may be your case.

I have never trusted pap smears in my care. I always go for a HRA once a year since I have been diagnosed with AIN2 dysplasia that was treated with infrared coagulation (IRC) and surgical removal. But some people are not lucky to have insurance or access to HRA, so a pap smear and digital exam are better than not doing anything.

Talk to your colon rectal doctor. I think he would agree that a clear HRA rules out any doubt found in a pap smear.

By the way, most HIV positive never clear HPV infection, even with higher CD4 cells and undetectable viral load.

You do not tell me how old you are, but if you are under 26, you may be able to get insurance to pay for the three rounds of HPV vaccine. The two vaccines that we have right now only protect those who have not been exposed to cancer producing HPV types. There is no way to know who has been exposed to them, but some studies show that long term survivors have most cancer producing genotypes. There is a genotype test approved for women but last time I tried to access it, I was denied. You may want to talk to your doctor about this.

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