No impact of ART on progression or regression of anal squamous intraepithelial lesions

Results from a French study of 94 HIV positive gay men who were followed prospectively, prior to starting ART, reported a lack of regression of AIN precursor lesions associated with anal cancer and no beneficial association with increased CD4 counts on ART.

This study, from Christophe Piketty and colleagues was published as a concise communication in the 28 January 2013 edition of AIDS. [1] Participants were enrolled from the Hôpital Pitié-Salpetrière, Paris between March 2006 and October 2007.

Patients were evaluated for anal cytology, histology and anal HPV DNA at 3 months prior to starting cART (baseline), month 12 and month 24 of ART. Anal cytology was classified as normal, atypical squamous cell of undetermined significance (ASCUS), atypical squamous cell that cannot rule out high grade SIL (ASC-H), low grade SIL (LSIL) and high grade SIL (HSIL). A single pathologist was responsible for all histology results and the most severe results were used.

Median (IQR) baseline characteristics included age 39.4 years (IQR 33.3-43.4), time since HIV diagnosis 2.3 years (IQR 1.0 – 3.9), CD4 count 301 (IQR 242 – 339) cells/mm3 and viral load 4.9 (IQR 4.3 – 5.2) log copies/mL.

In data from a sub-set of about 70 patients, median age at first intercourse was 20 (IQR 18-24) years and 66% had had more than 40 lifetime partners. Sexual activity included similar percentages of people having insertive and receptive anal intercourse, with approximately 45% estimated 1-100 times and 45% 100-1000 times. Only 7% estimated more than 1000 sexual experiences. Approximately 31% had a prior history of anal warts. 34% were current smokers and 16% were former smokers.

At baseline, 59% (45/76) of patients had an abnormal cytology results, with LSIL in 36% (27/76) and HSIL in 9% (7/76). After follow-up, these rates were 59% (40/68), 34% (23/68) and 15% (10/68) at month 12 and 52% (36/69), 33% (23/69) and 9% (6/69) at month 24, respectively.

The prevalence of any lesion at baseline was similar in patients with HPV-16 infection vs other oncogenic HPV genotypes (63% vs 53%, p=0.469) but HSIL prevalence was significantly different (18% vs 0%, p=0.013).

There was no significant relationship between ART, baseline or change in CD4, or viral suppression and the rate of acquisition or disappearance of anal lesions at any timepoint. Among patients with no lesion at baseline, 10 patients (35.7%) exhibited a SIL at month 12 (n=7 LSIL and n=3 HSIL). At month 24 these figures were n=5 LSIL and n=1 HSIL. Regression of anal lesions was observed, without specific therapeutic intervention, in all five patients with HSIL at baseline (n=4 to LSIL and n=1 to normal) at month 12; n= 2 ASC-H, n= 2 LSIL and n=1 normal at month 24.

At month 24, regression of the severity of lesions was observed in 44% (18/) patients with a lesion at baseline and new lesion occurrence was observed in 37% (10/27) without a lesion at baseline.

Piketty C et al. Lack of regression of anal squamous intrapathelial lesions despite immune restoration under cART. AIDS. 2013 Jan 28;27(3):401-6. doi: 10.1097/QAD.0b013e32835ad2cb.