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Title
Early detection of anal cancer in men who have sex with men (MSM) living with HIV by incorporating digital anorectal examinations (DARE) into routine HIV care: A prospective cohort study
Presenter
Jason J. Ong
Authors
J.J. Ong1,2, S. Walker2, A. Grulich3, J. Hoy2,4, T. Read2,5, C. Bradshaw2,5, S. Garland6, R. Hillman7, D. Templeton3, J. Hocking8, B. Eu9, B. Tee10, E. Chow2,5, C. Fairley2,5
Institutions
1London School of Hygiene and Tropical Medicine, London, United Kingdom, 2Monash University, Melbourne, Australia, 3Kirby Institute, University of New South Wales, Sydney, Australia, 4The Alfred Hospital, Melbourne, Australia, 5Melbourne Sexual Health Centre, Melbourne, Australia, 6University of Melbourne, Department of Obstetrics and Gynaecology, Melbourne, Australia, 7University of Sydney, Westmead Clinical School, Sydney, Australia, 8University of Melbourne, Melbourne, Australia, 9Prahran Market Clinic, Prahran, Australia, 10Victorian AIDS Council, Melbourne, Australia

Background: MSM living with HIV have the highest risk for anal cancer. The majority of anal cancers are detected in late stages where morbidity and mortality are high. We provide ''real-world'' data on the feasibility of incorporating regular DARE into routine HIV care for MSM living with HIV. We monitored the referral rate to colorectal specialists, which may be a driver of cost.
Methods: In 2014, we recruited 327 MSM living with HIV, aged 35 and above, from Melbourne, Australia. Men were recruited from one major sexual health centre(n=187), two high HIV caseload general practices(n=118) and one tertiary hospital(n=22). Men were followed for two years and DARE was recommended at baseline, year 1 and year 2. Data were collected regarding patient and physician experience, and health service use. An ordered logit model was used to assess the relationship between sociodemographic factors and the number of DAREs received (1, 2 or 3). Potential confounding factors such as the site of recruitment, income level and HIV duration were adjusted for.
Results: Men had a mean age of 51 (SD+9) years, were Australian born (69%), current smokers (32%), and had a mean CD4 of 630 (SD+265) cells per mm3, with no significant differences between clinical sites. Overall, 232(71%) men received all three DAREs, 71(22%) received two DAREs, and 24(7%) only had one DARE. The referral rate to a colorectal surgeon was 3.8 referrals per 100 DAREs: lowest in the sexual health clinic (1.7/100 DARE), followed by GP clinics (5.6/100 DARE) and the tertiary hospital (13.2/100 DARE, P=0.01). One stage 1 anal cancer and eight anal intraepithelial lesions were detected. Receiving a greater number of DAREs was associated with: age >50 years(adjusted odds ratio(AOR)=1.98, 95%CI:1.10-3.55), ex-smoker(AOR=`2.32, 95%CI:1.17-4.56), and current smoker(AOR=2.00, 95%CI:1.00-3.98).


Figure 1 DARE diagnoses at baseline, year 1 and year 2 visits for men who have sex with men living with HIV, Australia.
[Figure 1 DARE diagnoses at baseline, year 1 and year 2 visits for men who have sex with men living with HIV, Australia.]


Conclusions: Integrating an early cancer detection program into routine HIV clinical care is feasible, particularly in settings where anal cytology and high-resolution anoscopy services are unavailable. Though referral rates to colorectal surgeons remained low over the two years, there was heterogeneity depending on site of recruitment. An education program to up-skill HIV physicians in early anal cancer detection could reduce the number of referrals.

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