How often should individuals with a history of Human Papillomavirus (HPV) infection or HIV/AIDS undergo anal pap testing?

Anal Pap Testing Frequency

Routine anal cytology screening is not currently recommended by the CDC for any population, including those with HIV or HPV infection, due to insufficient evidence demonstrating that screening reduces anal cancer mortality or morbidity. 1

Current Evidence-Based Recommendations

What IS Recommended

• Annual digital anorectal examination (DARE) should be performed for persons with HIV infection and men who have sex with men (MSM) without HIV who have a history of receptive anal intercourse 1, 2
• DARE is used to detect palpable masses that could indicate early anal cancer 1, 2, 3
• The examination is acceptable to patients and has low risk for adverse outcomes 1

What Is NOT Officially Recommended (But Practiced)

The CDC explicitly states that data are insufficient to recommend routine anal cancer screening with anal cytology in persons with HIV infection, MSM without HIV infection, and the general population 1, 2

Practice Patterns Despite Lack of Official Guidelines

When Annual Anal Cytology Is Used in Clinical Practice

Despite the lack of official recommendations, some specialty centers perform annual anal cytology screening in the following high-risk groups 2, 4:

• HIV-positive MSM or persons with receptive anal intercourse: Annual anal cytology starting in early-to-mid 30s, but only if high-resolution anoscopy (HRA) capability is available 2, 4, 3
• HIV-positive heterosexual men/women: Annual screening starting age 45, only if HRA available and after informed discussion 2, 3
• Women with history of cervical/vulvar cancer or high-grade cervical lesions: Annual screening 4, 5
• All HIV-infected persons with genital warts: Annual screening 4

Critical Caveat About Screening Implementation

Do not implement anal cytology screening without access to HRA and biopsy services 2, 3. Abnormal cytology results require referral to HRA with biopsy for definitive diagnosis 2, 4, 3, making screening futile without this capability.

Why Official Guidelines Don't Recommend Routine Screening

Evidence Gaps

• No controlled studies demonstrate that anal Pap screening reduces anal cancer morbidity or mortality 1, 6
• More evidence is needed on natural history of anal intraepithelial neoplasia, best screening methods, safety and response to treatments 1

Test Performance Limitations

• Anal cytology has limited sensitivity (55-89%) and specificity (40-67%) for detecting high-grade squamous intraepithelial lesions (HSIL) 2, 6
• In the largest study of HIV-positive males, sensitivity ranged from 46% to 69%, with specificity from 59% to 81% 6

Treatment Limitations

• If HSIL is detected and treated, recurrence rates are extremely high: approximately 50% at 1 year and 77% at 3 years 2
• Multiple treatment modalities exist, but none prevent recurrence reliably 2

Risk Stratification by Incidence Rates

The CDC identifies distinct anal cancer risk levels per 100,000 person-years 1, 2, 3:

• MSM with HIV infection: 80-131 cases (highest risk)
• Men with HIV infection: 40-60 cases
• Women with HIV infection: 20-30 cases
• MSM without HIV infection: 14 cases
• Women with previous HPV-related gynecologic dysplasia/cancer: 6-63 cases
• General population: 1-2 cases (lowest risk)

Alternative Screening Intervals Based on Recent Research

For Patients with Normal Baseline Results

Recent evidence suggests that in patients with normal cytology and negative HPV16 at baseline, a three-year interval screening may be less burdensome than annual screening 7:

• Cumulative probability of high-grade AIN after 1 year: 0.4%
• After 2 years: 2.6%
• After 3 years: 7.5% 7

These probabilities are significantly lower than those with positive HPV16 at baseline 7.

Co-Testing Strategy

Recent data from 2025 shows that PAP-HPV co-testing provides superior performance compared to either test alone 8:

• Co-testing demonstrated 100% sensitivity and 100% negative predictive value for AIN2+ lesions 8
• Cytology alone: 74.2% sensitivity, 63.3% specificity
• HR-HPV testing alone: 96.8% sensitivity, 38.1% specificity 8

Common Pitfalls to Avoid

• Do not assume low risk despite negative initial screening in high-risk individuals; follow-up remains important 3
• Do not delay evaluation of abnormal screening results in high-risk individuals 3
• Do not screen without established referral pathways to HRA and treatment services 2, 3
• HPV testing is not clinically useful for anal cancer screening due to extremely high prevalence of anal HPV infection in high-risk populations 2

Bottom Line for Clinical Practice

For HIV-positive individuals or MSM with receptive anal intercourse history: Perform annual DARE starting in the 30s-40s based on risk level 2, 3. Consider annual anal cytology only if you have access to HRA services and the patient desires screening after informed discussion about the lack of proven mortality benefit, high false-positive rates, and high recurrence rates after treatment 2, 4, 3.

For HIV-negative individuals without high-risk behaviors: No routine screening is recommended 2, 3.