Screening for Anal and Cervical Dysplasia in HIV-Infected Patients

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Screening For HPV in MSM

In the current issue of prn notebook is an article on Screening for Anal & Cervical Dysplasia in HIV wriiten by Joel Palefsky.

............At the time of the initial screening, if the cytology is normal, it is recommended that an anal Pap smear be repeated annually for hiv-positive men, and every two to three years for hiv-negative men. If the patient is found to have lsil, routine follow-up should occur every six to 12 months without ne-cessitating therapy. As with cervical lesions,.................

...........Dr. Goldstone said, "is that men who have sex with men who have any signs of anal disease should be evaluated for anal sil. It's also important for primary care providers to keep lines of communication open in order to determine which patients are at risk for anal sil. Patients might not volunteer information about their sexual history or behaviors. It's up to providers to bring the topic up and to make their patients feel comfortable discussing sexual issues."

Screening Issues
there is no denying that cervical pap smear and colposcope screenings have had a profound effect on the incidence of cervical cancer, among both hiv-positive and hiv-negative women. If we are to assume that anal dysplasia is similar to cervical dysplasia in its natural history and patho-genesis, compounded by the seemingly high prevalence and incidence of hsil in certain populations, then isn't it possible that anal cytology screenings might play an invaluable role in detecting (and treating) high-grade dysplastic lesions, before they progress to anal cancer? According to Dr. Palefsky, the answer is most likely "yes," but not without potential caveats to consider. Discussing results from one of his cohorts of msm in San Francsico, Dr. Palefsky indicated that the sensitivity of anal Paps‹"tush Paps" as he refers to them‹to detect abnormal cytology was approximately 80% in hiv-positive men and 51% in hiv-negative men, roughly similar to the accuracy of cervical Pap smears in hiv-positive and hiv-negative women. However, anal Pap smears often yielded incorrect results re-garding the grade of anal dysplasia present‹ a number of lesions that were said to be of a low-grade variety upon con-ducting a Pap smear were actually high grade upon conducting high-resolution anoscopy and biopsy. "Anal Pap smears are definitely appropriate as initial screening strategies," commented Dr. Palefsky.

"But it's important that any abnormality be followed up with high-resolution anoscopy and that lesions be biopsied to confirm the grade of dysplasia." To conduct an anal Pap smear, a Dacron swab is inserted approximately 1.5 to 2 inches (approximately 3 to 5 cm) into the anal canal. "It's important to use a Dacron swab, not a cotton swab, as cotton clings to the cells and won't give them up easily for cytology," recalled Dr. Palefsky. "And be sure to moisten the swab with water, not lubricant. You'll want the Pap smears to be comfortable for patients without botching the sample." Once inserted deep enough into the anus‹this is necessary, in order to collect both rectal columnar and anal squamous cells‹the swab should be pulled out slowly, applying some pressure to the wall of the anus, rotating the swab in a spiral motion along the way. From there, the cells collected with the swab can be placed in the "ThinPrep" methanol fixative medium or spread onto a glass slide and dipped in fixative solution and, finally, shipped off to a cytology lab for analysis.

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