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3 Apr 2013

Very high incidence of high-grade pre-cancerous anal lesions among young HIV-positive Thai gay men

Extremely concerned by their findings, investigators recommend that healthcare providers, policy makers and communities of gay men need to make plans for screening and treating pre-cancerous anal lesions.

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Approximately a third of HIV-positive gay men in Thailand developed high-grade pre-cancerous anal lesions during just one year of follow-up, investigators report in the online edition of AIDS. Infection with high-risk strains of human papillomavirus (HPV) was an important risk factor for the development of high-grade lesions. The investigators were extremely concerned by their findings and recommend that healthcare providers, policy makers and communities of gay men will need to make plans for screening and treating pre-cancerous anal lesions.

HIV-positive gay men are the group most affected by anal cancer. The malignancy is preceded by anal lesions (anal intraepithelial neoplasia, AIN), which are usually associated with infection with high-risk strains of HPV.

Little is known about the prevalence and incidence of high-grade precancerous anal lesions (HGAIN) among gay men in low- and middle-income settings.

An international team of investigators therefore designed a prospective study involving 123 HIV-positive and 123 HIV-negative gay men in Bangkok, Thailand.

They were screened for anal lesions at baseline and again after six and twelve months. The participants also provided samples for anal cytology to determine the prevalence and persistence of infection with high-risk HPV strains (HPV 16/18).

The participants had a median baseline age of 28 years. The HIV-positive participants had a median baseline CD4 cell count of 343 cells/mm3. Only 13% of HIV-infected participants were taking antiretroviral therapy when the study started and 10% had an undetectable viral load. At the end of the study, the proportion of HIV-positive participants taking antiretrovirals had increased to 47%, and at the end of the study some 33% had an undetectable viral load and median CD4 cell count was 277 cells/mm3.

Baseline prevalence of high-grade pre-cancerous anal lesions was 19% among the men with HIV and 11% in the HIV-negative men.

During follow-up, 27% of HIV-positive men without HGAIN at baseline had developed pre-cancerous anal lesions, as had 7% of HIV-negative men.

The probability of having high-grade pre-cancerous anal lesions at month twelve was 29% for HIV-positive men to 8% for HIV-negative participants (p = 0.001).

Analysis of men with low-grade anal lesions at baseline showed that 33% of those with HIV and 13% of HIV-negative individuals progressed had HGAIN after twelve months of follow-up.

Anal infection with any strain of HPV was detected in 85% of HIV-positive and 59% of HIV-negative participants (p < 0.0001).

HIV-positive men were significantly more likely to be infected with a high-risk HPV strain than the HIV-negative men (58 vs 37%, p = 0.001).

Persistent high risk HPV infection was found in 47% of HIV-positive and 19% of HIV-negative participants.

Infection with HIV was associated with a more than three-fold increase in the risk of developing high-grade pre-cancerous anal lesions (HR = 3.26; 95% CI, 1.31-8.14; p = 0.011).

“MSM [men who have sex with men] with HIV infection in our study had approximately 2-3 times higher relative risk for incident HGAIN,” comment the authors. They believe this indicates “a role for immunodeficiency and/or HIV-HPV interactions in the development of HGAIN”.

Persistent infection with HPV 16/18 increased the risk of incident HGAIN by a factor of five (HR = 5.16; 95% CI, 1.89-14.08; p < 0.001).

“The high prevalence and incidence of HGAIN in our young MSM cohort is of great concern,” conclude the investigators, who note that as many as 15% of men with high-grade pre-cancerous anal lesions progress to anal cancer within three to five years. “Practitioners, policy makers, and communities will need to plan for strategies to screen for treat AIN using data available from their own setting.”

Reference

Phanuphak N et al. High prevalence and incidence of high-grade anal intraepithelial neoplasia among young Thai men who have sex with men with and without HIV. AIDS 27, online edition: DOI: 10.1097/QAD.0b013e328360a509, 2013.

This article was first published by NAM/Aidsmap.com and is republished with permission.

Reader's Comments

1. 2013-04-03 18:43
Vaccination against papillomavirus (HPV) is available for women but hardly any men would think of this possibility and neither would medical practitioners. Perhaps an additional strategy could be prevention and encouraging medical participation to offer this vaccination to HIV positive men
2. 2013-04-04 01:33
From what I can remember reading about the HPV vaccination (please correct me if I am wrong), it is only effective for a limited number of HPV strains, leaving gap in protection. Maybe more importantly, the vaccine must be administered well before exposure to any of the HPV strains. This is the reason its recommended that girls are vaccinated while still quite young. For most gay men, it appears it's too late to get any benefit from an HPV vaccination.

The research hints at another level of crisis potentially looming for gay men and, worryingly, one that might become more pressing than HIV itself as anal cancers are aggressive and difficult to treat successfully.

While I know many, if not most, of the community view sex as recreational and no big deal, Mother Nature keeps reminding us that there are life-altering and life threatening consequences that can easily arise from our common sexual practices. Viruses and bacteria that have developed regionally are spreading worldwide much more rapidly as a consequence of cheap travel and increased tourism/business travel. And, these viruses are swapping genetic material amongst their different cousin viruses spawning new viruses much more rapidly. This is a direct result of the high number of sex partners common in the MSM world, yielding multiple mixed viral combinations. It seems only a matter of time before HIV is displaced by yet another virus or even a bacteria as the leading cause of premature death amongst gay men.

I wonder, how many gay men worry about premature death when flying, taking a taxi ride in Bangkok or even eating poultry (bird flu) yet engage in sex with multiple partners in a year with little or no thought to potential consequences for themselves and others. Ho-hum
Comment edited on 2013-04-04 10:20:02
3. 2013-04-04 10:08
Hmmm ... so, we come back again to monogamy, sexual fidelity and even celibacy. Worth thinking about, perhaps? Comment#2 makes a whole lot of sense. Most of us worry about catching bugs from food and liquids when we visit third world countries but wouldn't think twice about wanton carnal behaviour even at the risk of catching life-altering or life-threatening diseases. When does it become important enough for us to start reversing that trend?
4. 2013-04-04 19:58
This is worrying, but is a set of 123 + 123 people significant? And how were they selected? Can one extrapolate this study on 246 people to the whole gay HIV+ population in Thailand, starting the article with

"Approximately a third of HIV-positive gay men in Thailand developed high-grade pre-cancerous anal lesions"

?

When I meet someone, I first want to meet him in person in an outside place (bar, or better, restaurant), to know the human being as much as the sexual partner. Only if I like what I hear and feel comfortable with him will I go on with sex.
5. 2013-04-05 09:07
#4, the p-values are very very low (low would be p < 0.01). I would say that their conclusions are statistically significant.

Although, they seem to have a pool of sickly people in the HIV+ camp. The median CD4 counts dropped from 346 to 277 during the study and only 13% were on meds at the beginning of the study. I would be interested to know what the data looks like for those who are already on meds and have managed to achieve Undetectable Viral Load.

#2, Do you think people have multiple partners because "it is no big deal"? Or do you think their body inherently wants it? Maybe take some time to think about how similar the arguments against polyamory is to the arguments against homosexuality.

IMHO, the only practical response when reading such a research would be "Ok, lets get more gay men vaccinated!"
Comment edited on 2013-04-05 09:34:24
6. 2013-04-05 14:08
#5, personally, I have absolutely no problem with practicality but I'm quite sure that there isn't yet a vaccination against HIV as there is one against, say, polio or hepatitis B. Which brings me back to my question : When does it become important enough for each of us to make changes in life-style or carnal habits/practices before life-altering or life-threatening diseases take over?
Comment edited on 2013-04-05 14:09:11
7. 2013-04-05 21:56
#6, Yeah I meant HPV vaccines. And as for your original question: Can we ever? There's already research linking anal sex to higher risk of anal cancer.

Also, just as an FYI and to derail the topic, there are people working on an effective vaccine for HIV. The last large-scale trial, HVTN 052, of a vaccine showed it to reduce transmission by 30%. Not a lot, but it is a start. :)
8. 2013-04-06 01:24
@changed86: I didn't make any arguments against polyamory. I consider arguments against homosexuality to fall into the categories of 1) moral & ethical arguments, primarily religious or procreative and 2) scientific arguments, primarily genetic and behavioral. While I object to moral and ethical arguments on the simple grounds that homosexual conduct happens between two consenting adult harming no one, I do not object to the genetic and behavior arguments (i.e. nature vs. nurture vs. a mix, evolutionary drivers, etc.) for the simple fact that they can broaden our understanding of the roots of behavior. I would consider the same to be true of arguments regarding polyamory.

At any rate, I didn't judge polyamory; rather I said it increases risk to exposure to potentially life-threatening or life-changing diseases that are preventable if one chooses to follow the accepted prevention practices. For STDs, that would mean condom use for both oral sex (Hep B/C, HPV, drug resistant gonorrhea, etc. are easily spread thru unprotected oral sex) and anal sex (the preceding plus HIV) and forgoing rimming altogether unless using a dental dam. Anything less increases both risk of contracting and risk of transmitting one or more diseases. And each additional partner with whom one fails to follow prevention practices increases this rapidly, while also increasing potential mutations and increasing drug resistance. Polyamory is not a problem; careless, ignorant choices are.
Comment edited on 2013-04-06 01:29:16
Comment #9 was deleted by its author on 2013-04-06 08:19
10. 2013-04-06 08:30
@slingtown: Thanks for clearing it up. Polyamory isn't the problem. Your earlier post seem to have implied that. Most studies on HIV would tell you that the best way to prevent it's spread is through the use of condoms (a small minority might advocate PrEP). No study ever recommends limiting the number of sexual partners to one (in that case, they might as well recommend limiting it to zero, hrm.. sound like the Republicans?). THIS HPV study also never made a comment or recommendation regarding the number of sexual partners. So I don't understand why whenever there is a study on these things, people tend to whip out the 'promiscuity clause'. As if that is the cause of all our problem. It is a matter of condom use. Plain and simple. No need to mention about multiple sexual partners.
Comment edited on 2013-04-06 08:35:49
11. 2013-04-06 13:26
@changed86: Three points, each significant. The first is about intent, in this case, my intent compared to your intent. To the former, I am clear as to what I intended to say and what, if any, implications I was intending to make. If you wish to question your understanding of my intention and or intended implications, it is simple matter to ask me "I infer from your statement XXX that you believe [advocate/condemn/or other verb you consider appropriate] YYY; do I infer correctly?" It is both the polite way to check understanding and NOT saddle the other with responsibility for your point of view which, as in this case, may be wrong both in substance and character. It is the province of the insecure ego/intellect to make a personal attack when not being certain he fully understands the intention of the other.

The second point is that study sighted in this article was comparative, looking at incidence of anal lesions, HPV and HIV, with HIV status being the control. Apparently, it did not look at causal factors, nor compare risk behaviors between HIV- and HIV+ participants, nor does it seem to have used a control group of non HPV+ participants to determine the significance of new vs. old HPV infection on development of anal lesions. As such, the study does not make recommendations regarding prevention, nor treatment, only a "this is what we see as a health risk amongst MSMs, not even comparing the risk amongst non-MSMs. And, I would recommend you take note that this is the norm food such studies,

There are, however, multitudinous HIV and other STD studies concerned with the processes for exposure, transmission, transmission risks, exposure risks, prevention methods and prevention effectiveness. These often do include conclusions geared towards recommendations for prevention, treatment and possibly both.

I point this out because you are quite wrong about no study EVER recommending limiting sexual partners in order to reduce of HIV infection. Many, if not most, HIV studies focused on prevention methodologies include the limiting of sexual partners as a method for reducing risk. Please don't take my word for it; feel free to sample information freely available on the web.

Finally, regarding your comments about people whipping out the "promiscuity clause" and "as if that is the cause of all our problem,". I'd point condoms are only 100% effective when you have no reason to use them. From the moment you have reason to use a condom, its effectiveness is reduced due to incomplete use, user error, or condom failure. Increasing the number of sexual partners increases risk, even when the risk is significantly mitigated with 100% condom use.

As an HIV+ individual, you are surely aware of the difficulty in determining the infection point for many men that sero-convert, so much so that no study has been able to prove whether unprotected oral sex is a safe sexual practice or just safer practice where HIV transmission occurs. Hence, there are significant caveats about swallowing, tooth-brushing before/after, mouth sores, etc. And sorry to point out that HIV isn't the only problematic STD which is the point of this article; other STDs are readily transmitted through oral sex, rimming and a few can even be transmitted through heavy kissing under the right circumstances. So you can prattle away about how recommending limiting sexual partners sounds like some neo-con, homosexual polyamory-hating Republican ideology...but that says something about your own refusal to see that ALL prevention options should be put out there so that people can make informed, responsible choices to protect their heath and the health of others. Let's face it, beyond cases of rape, tainted blood transfusions and accidents involving tainted blood, HIV infection is a consequence of the choices we make with their inherent risks, however small, in light of all available information.

So, please don't let your myopic (and what I infer as self-serving) views about sexuality and disease prevention prevent others from hearing ALL the risk and prevention options available. You've made your choices, please don't interfere with others' access to ideas and info that might help them avoid contracting or spreading one or more life-changing, life threatening diseases.
12. 2013-04-06 17:22
Maybe I have not read enough. Do point me to studies which conclude by advocating limiting sexual partners as a disease prevention option. Studies done by scientists, not policies written by governments.

Advising abstinence as a disease prevention option didn't work before, advising people to limit their sexual partners won't work now. And yes, to me, they are very similar advice. So really, the only thing that is worth advising is "condoms condoms condoms!". Or in the case of HPV, get vaccinated.

So apparently I have a myopic view of sexuality and disease prevention. And I've been implicated to have an insecure ego. Hrm, if you have anything else of that nature to say, please write it in a PM.
Comment edited on 2013-04-06 17:29:46
Comment #13 was deleted by its author on 2013-04-08 08:37
14. 2013-04-08 08:37
Hi, changed86, I totally agree that condom use is the most effective means of preventing HIV infection that we currently have. Having said that, to deny personal responsibility for one's sexual or carnal practices/habits is, in my view, a cop out. Alcoholics Anonymous will tell you that the key to an alcoholic's recovery is OWNERSHIP of the cause and the problem. Sexual habits, much like drinking habits, are not independent or freak phenomena. They are completely within OUR control and indeed emanate from OUR inclinations, impulses and thoughts. The consequences of one's sexual proclivities and actions are somewhat less within our control BUT they are definitely a direct result of OUR lifestyle choices. To completely put the problem "out there" and not "in here" is, to me, a complete denial of one's key role in the causal sequence and is but a poor attempt at shirking one's RESPONSIBILITY for one's actions.
Comment edited on 2013-04-08 16:28:40

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