The sexually transmitted human papillomavirus (HPV), which causes genital warts (basically harmless) and can cause anal, cervical and oral/throat cancer (not so harmless), is everywhere. Nearly half of American adults are infected with it, according to a new government report, with 25% of men and 20% of women having high-risk HPV types. And those types account for about 31,000 cancer cases annually.
What's more, HIV-positive folks, especially those with low CD4 counts, are far more vulnerable to HPV-related pre-cancer and cancer. HIV-positive women have "significantly higher" rates of cervical cancer compared with HIV-negative women, says Mark Einstein, M.D., at Rutgers Medical School in New Jersey. And as for anal cancer, according to Joel Palefsky, M.D., of the University of California, San Francisco, HIV-positive men and women have 131 and 30 cases of anal cancer per 100,000 people, respectively, versus 37 cases per 100,000 HIV-negative gay men and a mere two cases per 100,000 HIV-negative women.
This is why, if you're HIV positive, it's important that you're up-to-date on HPV screening and treatment and that you advocate for yourself. For one thing, if you're below the age of 27 or you've had little or no sexual experience, you are still a possible candidate for Gardasil-9, the HPV vaccine. According to Stephen Goldstone, M.D., FACS, at New York City's Mount Sinai Hospital, it's not yet known whether the vaccine is effective in HIV-positive people -- but it does produce HPV antibodies in HIV-positive people, which is a good sign.
But the truth is, most of us have already been exposed to HPV, which is why screening is so important. Generally speaking, says Goldstone, you should get an annual cervical or anal cytology (cis women and transgender men should get both) -- also known as a Pap smear -- and a digital rectal exam. You must bring it up with your health provider and, if they can't or won't do it, ask them to help you find a provider in your region who does. Cervical and anal cancers are potentially preventable if detected in the pre-cancer stage. That's why annual screenings are so important.
Sadly, unlike with cervical cancer, there are currently no standard national recommendations for routine screening of anal cancer, and it's often more likely to be done at LGBT-specializing clinics. "From my vantage point," says Wendy Armstrong, M.D., FIDSA, head of the HIV Medicine Association, full screening "is still not widely available at all, and where it is, capacity is often a limiting factor."
However, those of you in or near 12 major U.S. cities (mostly on the coasts, but with more coming) now have a new way to get screened: via the ANCHOR Study. Led by Palefsky, ANCHOR is a multisite, National Institutes of Health-funded study to determine whether the best thing to do for HIV-positive folks with HPV-related pre-cancer is to treat immediately or to watch and wait.
Any HIV-positive person 35 years old or older is eligible to be screened for the study if they have not had treatment for anal precancerous growths or anal cancer in the past. The study will help establish anal cancer screening as standard of care if it shows that treating pre-cancers is useful in preventing anal cancer. The investigators are hoping to screen as many HIV-positive men and women as possible.
"We're also looking at quality-of-life with treatment," says Goldstone, one of the study doctors. Much as with prostate cancer, he adds, "we used to think everybody needed to be treated for prostate cancer, but now we know that some people never go on to die from it. We are trying to look at the same issues with anal pre-cancers. We know that many will never advance to cancer and some might even resolve spontaneously without treatment. We are hoping to understand which pre-cancers are dangerous and put people at risk for progressing to cancer."
The study will treat cases that become cancer with either local excision or, in more advanced cases, chemotherapy and radiation. "It's highly curable," says Goldstone.
But getting back to screening: After an anal Pap, if abnormalities are found, your provider might give you a colposcopy (cervix) or high-resolution anoscopy (anus), a painless and brief if perhaps slightly uncomfortable procedure in which your provider inserts a little plastic microscope into your anus or vagina to look for abnormal growth. If it's found, your provider might snip out (it can pinch) a tiny bit to biopsy to see whether the growth is precancerous.
And, oh, one more thing: The two biggest things you can do as an HIV-positive person to reduce your chances of getting anal, cervical or oral/throat cancer is to stay undetectable on HIV meds and keep your CD4 count as high as possible -- and not to smoke. So, if you smoke, the next time you bring up your Pap smear with your provider, also ask them what help (the patch, perhaps?) they can give you in kicking butt(s)!