Studies highlight problems of rectal disease in HIV-positive patients
Graham McKerrow, HIV i-Base
Two studies highlighted the problems of rectal disease in HIV-positive patients, with one study showing anal infection by Human Papillomavirus (HPV) to be almost universal in men infected with HIV. The second study concluded that routine rectal Pap screening is feasible and warranted as part of HIV primary care.
Fortin and colleagues in Montreal, Canada, and at Roche Molecular Systems in California, USA, found anal HPV DNA in 135 (97.8%) of 138 anal samples from 113 men.  They also found that anal HPV infection was often caused by multiple HPV genotypes and that high-grade anal intraepithelial lesions (AIN) contained a greater burden of different types.
The most frequent genotypes identified were types 16, 6, 52, 45 and 18 found in 58, 47, 52, 45 and 18 men respectively. Of the newer types studied, four were detected in at least 20 specimens (types 61, 70, 73, 84). HPV-57 was the only type undetected in the cohort. Of 90 men with anoscopy results, 36 were normal, 36 had AIN grade I, and 18 had AIN grade II-III on biopsy. HPV-16 was detected in 12 (33%) of 36 normal men versus 11 (61%) of 18 men with AIN II-III (P=0.05).
All 18 men with high-grade AIN were infected with at least one oncogenic HPV type. A greater number of oncogenic types were identified in specimens from men with high-grade AIN (median of 4, range of 0–9) than normal men (median of 2,5, range of 0–6) (P=0.04, Mann-Whitney).
Norton and colleagues at the Boriken Community Health Centre in East Harlem, New York, recommend routine rectal Pap screening as part of HIV primary care medicine. They say their data support the findings of other groups that have identified a significant prevalence of rectal dysplasia and anal squamous intraepithelial lesions (SIL) among HIV-positive patients, and conclude from the results of their study that the course of rectal disease among HIV-1 infected patients needs additional characterisation. 
Their ongoing study of 115 patients, mostly Latino Hispanic subjects and Black/African Americans, found that 70 (69%) were negative for malignant cells.
Thirty-four patients (30%) were found to have some level of rectal dysplasia. In two patients (1.7%) an inadequate sample was reported by pathology. They found the following levels of rectal dysplasia: five patients had high grade lesions and SIL grade III; seven patients had moderate dysplasia and SIL grade II; 12 patients had mild dysplasia and SIL I; and 14 patients had atypical squamous cells of undetermined significance.
Unless stated otherwise, references are to the programme and abstracts of the 2nd IAS Conference on HIV Pathogenesis and Treatment, 13-16 July 2003, Paris.
- Fortin C, Rouleau D, Trépanier JM et al. Anal infection by Human Papillomavirus is universal in HIV-seropositive men. Abstract 941.
- Norton M, Milano D, Vane C et al. Practicality of and results from rectal Pap smears among patients receiving primary HIV care at a community health centre, NYC, USA. Abstract 945.