HIV This Week

Hessol NA, Holly EA, Efird JT, Minkoff H, Schowalter K, Darragh TM, Burk RD, Strickler HD, Greenblatt RM, Palefsky JM. Anal intraepithelial neoplasia in a multisite study of HIV-infected and high-risk HIV-uninfected women. AIDS. 2009;23(1):59-70.

Hessol and colleagues studied anal intraepithelial neoplasia and its associations with anal and cervical human papillomavirus (HPV), cervical neoplasia, host immune status, and demographic and behavioural risk factors in women with and at risk for HIV infection. They undertook a point-prevalence analysis nested within a prospective study of women seen at three clinical centres of the Women’s Interagency HIV Study. In 2001-2003 participants were interviewed, received a gynaecological examination, anal and cervical cytology testing and, if abnormal, colposcopy-guided or anoscopy-guided biopsy of visible lesions. Exfoliated cervical and anal specimens were assessed for HPV using PCR and type-specific HPV probing. Logistic regression analyses were performed, and odds ratios (ORs) estimated risks for anal intraepithelial neoplasia. Four hundred and seventy HIV-infected and 185 HIV-uninfected women were enrolled. Low-grade anal intraepithelial neoplasia was present in 12% of HIV-infected and 5% of HIV-uninfected women. High-grade anal intraepithelial neoplasia was present in 9% of HIV-infected and 1% of HIV-uninfected women. In adjusted analyses among HIV-infected women, the risk factors for low-grade anal intraepithelial neoplasia were younger age [OR = 0.59, 95% confidence interval (CI) = 0.36-0.97], history of receptive anal intercourse (OR = 3.2, 95% CI = 1.5-6.8), anal HPV (oncogenic types only OR = 11, 95% CI = 1.2-103; oncogenic and nononcogenic types OR = 11, 95% CI = 1.3-96), and cervical HPV (oncogenic and nononcogenic types OR = 3.5, 95% CI = 1.1-11). In multivariable analyses among HIV-infected women, the only significant risk factor for high-grade anal intraepithelial neoplasia was anal HPV infection (oncogenic and nononcogenic types OR = 7.6, 95% CI = 1.5-38). Even in the era of highly active antiviral therapy, the prevalence of anal intraepithelial neoplasia was 16% in HIV-infected women. After controlling for potential confounders, several risk factors for low-grade anal intraepithelial neoplasia differed from risk factors for high-grade anal intraepithelial neoplasia.

Editors’ note: In addition to these striking findings on low-grade and high-grade anal intraepithelial neoplasia in women with HIV infection, this study found an 80% prevalence of anal human papillomavirus (HPV) infection, exceeding the 45% prevalence of cervical HPV. Cervical HPV infection may serve as a reservoir and source of anal HPV infection or vice versa, with anal HPV infection possibly easier to detect. If these findings are corroborated, they may affect recommendations for screening for anal HPV infection and disease in HIV-positive women.