Challenges in the implementation of a high-resolution anoscopy clinic for people with HIV in an oncologic center in Mexico City.

Abstract

Background: Anal cancer incidence is increased in people with HIV (PWH), up to 60 times higher in men who have sex with men, and almost 15 times higher among women with HIV. Screening and treating high-grade lesions (HSIL) have proven to reduce the incidence of invasive anal cancer. In 2020, we started implementing a high-resolution anoscopy (HRA) clinic at INCan, a tertiary care oncologic center, as part of a screening program for PWH from the HIV clinic.

Objectives: We describe the barriers and difficulties in implementing an HRA Clinic from January 2020 to April 2021, including physician training, the certification process, discrepancies between cytology and histopathologist results, and the lack of experience of gastrointestinal pathologists in HPV-related lesions.

Results: During the first 18 months of the HRA clinic implementation, 124 studies were performed, and 85 biopsies were done. The prevalence of HSIL was 22%. Initially, when a gastrointestinal pathologist reviewed anal canal biopsies, a second opinion was requested from a genitourinary pathologist who examined 72 of the biopsies; there were discrepancies in the diagnosis in 61% of the cases, with more advanced intraepithelial lesions in 43% of cases. Specifically, gastrointestinal pathologists missed 68% of HSILs. The difficulties we faced were not having access to adequate anoscopes. Training and certification are a long way to go. Also, women's reachability was low.

Conclusions: Diagnosis and management of anal HSIL have become a standard of care in the prevention of Anal Carcinoma in PWIH, the population with the highest incidence of this neoplasia. Implementing HRA programs requires correct supplies and equipment, which are not always locally available; investing in physicians' training and an experienced pathologist in HPV-associated lesions interpretation is also imperative. More advocacy is needed for HIV programs to incorporate and invest in anal cancer screening.