Human papillomavirus-associated anal squamous intraepithelial lesions in men who have sex with men and transgender women living with and without HIV in Karachi Pakistan: implications for screening and prevention

Abstract

Background Anal squamous intraepithelial lesions (ASIL), strongly related to human papilloma virus (HPV) infection, is more prevalent among men who have sex with men (MSM). However, no such data are available for Pakistan yet, and neither HPV vaccination nor anal-cytology screening is implemented in Pakistan. The purpose of this first ever study was to assess the prevalence of HPV-related anal cytological abnormalities among MSM and transgender women living with and without HIV infection in Pakistan. Methods We conducted a cross-sectional study from March 2016 to November 2017 at sexual health centers run by the Perwaaz Trust and the National AIDS Control Program in Karachi. The study enrolled MSM and transgender women aged greater-than-and-equal-to-18-years who reported anal sex in the preceding 6 months. We collected two anal samples for liquid-based cytology and HPV type testing by PCR, and socio-demographic and behavioral data were collected through face-to face interviews. ASIL and its associations with biological and behavioral risk factors were analyzed through Cox regression for prevalence ratios (PR) and corresponding 95% confidence intervals (CIs). Results Out of 271 qualifying participants, 79% were MSM and 21% transgender women. The mean age was 28.8 (± 8) years. Almost 35% (93/271) of the study population had ASIL detected, ASIL was significantly more common among participants living with HIV than in HIV negative ((50/118) 42.4%; vs. (43/153) 28.1%) (p ≤ 0.001). Among ASIL, 66% (61/93) had low-grade squamous intraepithelial lesions (LSIL), and 3.6% (3/93) had high-grade squamous intraepithelial lesions (HSIL). The overall, HPV16 positivity was 35.5% (33/93) among all abnormal anal lesions and all 3 HSIL were HPV16 positive, however, HPV16 positivity could show its association with ASIL detection in univariate model only (PRcrude: 2.11(1.39–3.18)). Moreover, any HR-HPV type (PR 3.04; 95% CI 1.75–5.26), concurrent sexually transmitted infection (STI) (2.13; (1.28–3.55)) and HIV + /HPV + coinfection (1.75; (1.07–2.88)) remained independently associated with ASIL in the multivariate model. Conclusions Abnormal anal cytology among MSM and transgender is prevalent enough to consider optimal screening regimens. Further studies are required to see if periodic anal cytology can be made part of HIV care and treatment programs among MSM in Pakistan.

Development of a multivariable prediction model for anal high-grade squamous intraepithelial lesions in persons living with HIV in Puerto Rico: a cross-sectional study

“… 32 The observed significant association between anal HSIL and history of infection with any gonorrhoea in our data was surprising. However, studies have reported that sexually transmitted infections (STIs) such as chlamydia and gonorrhoea increased the risk of anal squamous intraepithelial lesions 28 and anal cancer. 33 Moreover, McCloskey et al reported that the seropositivity for HIV, HSV-2, T. pallidum , HBV, and HCV and history of gonorrhoea or chlamydia exert a powerful amplifying factor increasing the risk of anal HSIL above the risk of HR-HPV infection alone in both HIV-positive and HIV-negative patients.…”

Advances and challenges in sexually transmitted infections prevention among men who have sex with men in Asia

“…Over half of participants tested positive for HIV or another STI (HSV-2, syphilis, gonorrhea, orchlamydia) in a cross-sectional community-based study of MSM in Hanoi, Vietnam, and the prevalence of HIV, HSV-2, syphilis, gonorrhea, and chlamydia was 10%, 4%, 13%, 34%, and 19%, respectively [ 19 ]. Overall HPV infection prevalence among MSM and TGW was 66.4% in Pakistan, and the substantial risk of them to develop anal cancer was high, particularly for those with a concurrent HIV infection [ 20 ]. In Japan, the overall prevalence of high-risk human papillomavirus positivity was 59.7%, with HIV-infected MSM (68.9%) having a significantly higher rate than HIV-uninfected MSM (40.6%) [ 21 ].…”

Integration of human papillomavirus associated anal cancer screening into HIV care and treatment program in Pakistan: perceptions of policymakers, managers, and care providers

“…Certain at-risk groups such as gay, bisexual, and other men who have sex with men (MSM) particularly those MSM who are infected with HIV are at increased risk of HPV infection and are disproportionately affected by HPV associated genital warts, anal cancer and its precursor high-grade squamous intraepithelial lesions [ 5 ]. Recently study conducted in Pakistan by our group found 65% prevalence of HPV infection [ 6 ] and 35% of anal precancerous lesions [ 7 ] in MSM and transgender women living with and without HIV. HPV infection is an important risk factor for both cervical and anal cancers and causes similar type of squamous intraepithelial precancerous lesions, cervical intraepithelial neoplasia (CIN) and anal intraepithelial neoplasia (AIN), respectively.…”