What are the recommendations for anal and cervical PAP (Papanicolaou) testing for cancer screening in men and women living with Human Immunodeficiency Virus (HIV)?

Cervical and Anal PAP Testing for Cancer Screening in HIV-Positive Individuals

HIV-infected women should undergo cervical Pap smear screening twice in the first year after HIV diagnosis (at baseline and 6 months later), then annually if both tests are normal, while anal Pap testing should be performed for men who have sex with men, women with a history of receptive anal intercourse or abnormal cervical Pap results, and all HIV-infected persons with genital warts. 1, 2

Cervical Cancer Screening in HIV-Positive Women

Initial Screening Protocol

• Perform cervical Pap smear at the time of HIV diagnosis 1, 2
• Repeat Pap test 6 months after initial screening 1, 2
• If both initial tests are normal, transition to annual screening thereafter 1, 2

Management of Abnormal Results

• Any epithelial cell abnormality (atypical squamous cells, squamous intraepithelial lesion, glandular cell abnormalities, or squamous cell carcinoma) requires colposcopy and directed biopsy 1, 2
• Women with high-grade squamous intraepithelial lesions (HSIL) or squamous cell carcinoma must undergo immediate colposcopic examination 1
• After treatment for cervical dysplasia, monitor with frequent cytologic screening and colposcopic examination for recurrent lesions, as HIV-infected women have increased recurrence risk 1

Special Populations

• HIV-infected women who have undergone hysterectomy, particularly those with a history of abnormal cervical cytology before or at the time of the procedure, remain at increased risk and should continue regular Pap smear screening 1, 2
• Follow similar screening intervals as women who have not undergone hysterectomy 1

HPV Co-Testing Considerations

• For HIV-infected women over age 30 with CD4 counts >500 cells/µL who have negative Pap and HPV testing, consider extending screening interval to 3 years (similar to HIV-negative women) 1
• This approach is supported by evidence showing comparable low incidence of squamous intraepithelial lesions over 3 years in this specific subgroup 1

Anal Cancer Screening in HIV-Positive Individuals

Target Populations for Anal Pap Testing

Anal Pap tests should be performed for: 1

• Men who have sex with men (MSM)
• Women with a history of receptive anal intercourse
• Women with abnormal cervical Pap test results
• All HIV-infected persons with genital warts

Screening Frequency

• Annual anal Pap testing is recommended for high-risk groups, though no universally accepted formal screening programs exist 3
• The New York State Department of Health AIDS Institute specifically recommends annual screening for HIV-positive MSM and HIV-positive women 3

Follow-up of Abnormal Results

• Any abnormal anal Pap smear findings (atypical squamous cells of undetermined significance or worse) require high-resolution anoscopy with biopsy of abnormal areas 1, 3
• Topical therapy should be applied for high-grade dysplastic lesions identified on biopsy 3

Important Clinical Considerations

Strength of Evidence

The cervical screening recommendations are based on moderate to high-quality evidence, while anal screening recommendations carry weaker evidence (weak recommendation, moderate quality evidence) 1. Despite this, the significantly elevated risk of anal cancer in HIV-positive MSM (70 per 100,000 compared to 1-2 per 100,000 in the general population) justifies screening in high-risk groups 4.

Common Pitfalls to Avoid

• Do not skip the initial two cervical Pap smears before transitioning to annual screening - this can delay diagnosis of rapidly progressive disease in newly diagnosed HIV-positive women 2
• Do not discontinue cervical screening in women who have undergone hysterectomy if they had a history of abnormal cytology - these women remain at elevated risk 1, 2
• Do not rely solely on anal cytology - research shows poor agreement between cytology and high-resolution anoscopy findings (kappa 0.16-0.40), with cytology detecting only 19.5% of biopsy-confirmed high-grade dysplasia 5
• Do not assume standard-risk HIV patients are at low risk for anal dysplasia - one study found 16.3% of standard-risk HIV patients had high-grade anal dysplasia on biopsy 5

HPV Vaccination

• HPV vaccination is strongly recommended for all HIV-infected females aged 9-26 years and all males aged 9-21 years 1
• Males aged 22-26 years should also be vaccinated if not previously vaccinated 1
• Vaccination should be given in a 3-dose series, ideally starting at age 11-12 years 1