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HIV and monitoring for HPV
Mar 16, 2014

Dear Doctor,

What is the current standard of care for one who is over 50, gay male, HIV+, and with an earlier history of high-grade anal dysplasia?

In 2004 I was diagnosed with high-grade anal dysplasia by way of a standard anal pap smear. I also had two or so small residual warts left over from much earlier treatment in the same region. I was treated for all of this with several visits in the following two years. A few years after that I moved elsewhere and got a follow-up exam in a surgical hospital clinic and had one additional small external wart removed at that time.

Since relocating to that new area I have gotten anal pap smears more or less annually, and on one occasion a full-scale rectal exam while sedated. So far, there has been no further detection of dysplasia warranting treatment. After a follow-up check-up one year ago the surgeon said there was really no further need for to visit him and that I should just carry on with my regular HIV doctor.

At the time of my most recent infectious disease clinic hospital visit for a check-up one month ago, and one year since my most recent surgical exam, I asked the HIV doctor if I should start having regular pap smears in his clinic as an annual check-up, but he didn't seem to think this was warranted. In response to my concern, he obliged me with a very cursory external glance at the anal region, and declared that I was fine.

In light of all this, how should I monitor my anal health with regard to HPV? I thought that everyone over 50 was advised to get annual rectal exams, regardless of HIV status, much less with a history of HPV dysphasia. If it's really not a problem, I don't mind ignoring this, but I'm leery of simply waiting until I might have symptoms, as that could make treatment harder.

I'm male, now 52, HIV+ for around 28 years, taking Atripla for 9 years (starting one year after diagnosis with high-grade dysplasia, when my CD4 count was much lower), CD4 now 750, undetectable.

What would you advise for ongoing monitoring?

Response from Dr. Young

Hello and thanks for posting.

While there are many differences in opinion on this (and use by clinicians), the most current and progressive HPV guidelines are from the New York State Department of Health AIDS Institute.

In brief, the guidelines recommend doing annual rectal physical examination and for HIV+ men who have sex with men (or anyone with a history of anogenital pap abnormalities), an annual anal pap smear. If your doctor doesn't yet do this, discuss the guidelines in a supportive, yet encouraging way. If he's not comfortable doing this, simply ask politely if he can collaborate with someone to accomplish the pap.

Hope that helps, BY



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