Rates of Human Papillomavirus (HPV)-related anal and cervical cancer remain elevated among people living with HIV with rates of anal cancer among men living with HIV who have sex with men up to 80 times higher than in the general population.
By Kate Salters, PhD, MPH, Post-doctoral fellow, Epidemiology and Population Health ProgramandDr. Marianne Harris, MD, CCFPC, Clinical Trials Physician, BC Centre for Excellence in HIV/AIDS
At the height of the HIV and AIDS crisis, skin lesions caused by Kaposi sarcoma, a rare type of cancer, were a clear, visual indication of an HIV/AIDS diagnosis, fuelling stigma and discrimination. Now, with modern antiretroviral therapy (ART), these “AIDS-defining” cancers are rare. Still, we now face a newer, less visible threat: the emerging risk of other cancers that are often related to other viral infections.
According to a recent study published with the COAST cohort, non-AIDS defining cancers, including cervical and anal cancer, are now the leading non-HIV related cause of death among people living with HIV.
In this post-ART era, the rates of Human Papillomavirus (HPV)-related anal and cervical cancer remain elevated among people living with HIV.Cervical cancer rates may be two to four times higher among women living with HIV compared to HIV-negative women. Even more strikingly, the rates of anal cancer among menliving with HIVwho have sex with men (MSM) are up to 80 times higher than in the general population.
While much debate circulates around what drives these high rates of infection-related cancers, there is an immediate need to address the heightened cancer risk among people living with HIV in the province.
A solution could lie in the HPV vaccine, which may reduce the risk of HPV-related cancers of the mouth and throat, vulva, anus, and cervix. The newer 9-valent HPV vaccine may provide protection against HPV infection for up to 90% of cancer cases, an increase of 20% from the older quadrivalent vaccine. The efficacy and safety of the quadrivalent HPV vaccine among women living with HIV has been demonstrated by colleagues at the Women’s Health Research Institute.
While this is a step in the right direction, special attention must still be paid to HIV clinical outcomes, as HIV viral suppression is a key predictor of optimal effectiveness of the HPV vaccine. Moreover, there remains limited uptake of the vaccine among women living with HIV.
For the general population of women over the age of 21, cervical cancer screening through a “Pap test” is recommended once every three years. However, the recommendation remains for annual Pap tests for women living with HIV. Unfortunately, research out of Ontario suggests the proportion of women living with HIV who are completing annual Pap tests has now declined. In 2013, only one-quarter of women living with HIV in the study had received a Pap test.
The lack of evidence-based screening and management recommendations leaves many physicians wondering what to do. Evidence is conflicting regarding the benefit of anal Pap screening, and this test is not widely available outside of research settings.
Cervical and anal cancer screening in Canada should include routine HPV testing and, as of yet, there are no guidelines for anal cancer screening specific to people living with HIV.