Cancer Ribbon Colors, Meanings, and Months
Anal Cancer And HIV
Key pointsAnal cancer is a disease in which cancer cells are present just inside or immediately outside the anus.
Most cases of anal cancer are linked to human papillomavirus (HPV), a very common infection that can be passed on during sex. HPV is not a single virus – there are about 150 types of HPV that have different effects. Some types of HPV don't seem to do any harm, other types can cause anal and genital warts, while others can cause anal and cervical cancer. HPV16 and HPV18 are the types most likely to cause cancer.
Most adults have had HPV infection. Very often, the body can get rid of the virus without you ever knowing you had it. When you have HIV, your body might find it more difficult to get rid of HPV on its own.
A small number of people who have HPV develop abnormal cell changes in or around the anus. This is not cancer. And most people who have these abnormal cells do not go on to have cancer. It is important to distinguish between:
You can reduce your risk of HPV and cancer by getting vaccinated. HPV vaccination can prevent several cancers (including anal and cervical cancer) and also genital and anal warts.
The younger you are, the more likely you are to benefit. If you are older, it is more likely that you have already been exposed to several types of HPV, making the vaccine less effective.
The British HIV Association recommends that the following groups of people living with HIV receive the HPV vaccine:
Vaccination involves taking a course of three injections, over a six-month period. While younger people who do not have HIV may be given one dose, three doses are recommended for people with HIV. You can ask your HIV or sexual health doctor about getting vaccinated.
Using a condom during sex can also help to prevent HPV infection.
Who is at risk?High-grade AIN and anal cancer are rare in the general population, but rates are much higher in people with HIV and other individuals with weakened immune systems.
People who have had anal sex as the receptive partner ('bottom'), more sexual partners or genital warts are more likely to be infected with multiple types of HPV. This makes high-grade AIN and anal cancer more likely.
Nonetheless, high-grade AIN and anal cancer can develop in people who have never had anal sex or HIV.
Smoking makes abnormal cell changes happen more quickly. Stopping smoking can reduce your risk of anal cancer and may help prevent high-grade AIN progressing to cancer.
The risk of high-grade AIN and anal cancer increases as you get older.
Women who have previously had abnormal cervical screening results have a higher risk of anal cancer than other women. This is because HPV can spread between the genitals and the anus.
Anal cancer in people living with HIVPeople living with HIV are at much greater risk of having high-grade AIN or anal cancer than people without HIV. It seems that HIV's effect on the immune system reduces the body's ability to keep HPV infection under control.
Gay and bisexual men living with HIV have the highest risk of developing anal cancer. However, women and heterosexual men with HIV also have a higher risk of anal cancer compared to people without HIV. That's why screening and preventing anal cancer is important for all people living with HIV.
aidsmap's Susan Cole talks about cancer and HIV.
Taking effective HIV treatment significantly lowers your risk of developing cancer. A higher CD4 count and CD4/CD8 ratio are both linked to lower risks of cancer in people with HIV. Nonetheless, anal cancer can occur in people taking effective HIV treatment. Because people with HIV are living longer, cancers like this have more time to develop.
If you are diagnosed with anal cancer but haven't been tested for HIV, your doctor will discuss HIV testing with you. This is because people who have anal cancer sometimes have HIV without realising it.
SymptomsAnal cancer can cause symptoms in the anal area, including bleeding, pain, discomfort, itching, small lumps or ulcers on or inside the anus, a discharge, and difficulty controlling your bowels.
Sometimes, anal cancer doesn't cause any symptoms at all. And sometimes symptoms can be similar to other common, less serious health problems, like piles (haemorrhoids) and anal fissures.
People with low or high-grade AIN often have no symptoms, but sometimes it causes similar symptoms to anal cancer.
If you have any symptoms, it's worth having them checked by a sexual health doctor or your GP. While some people are embarrassed or uncomfortable discussing this area of their body, it's not unusual for doctors to examine the anus.
Diagnosis and monitoringA clinical trial in the United States has found that screening and early treatment of high-grade AIN reduces the rate of anal cancer in people living with HIV by more than half (57%):
These results support the inclusion of screening and early treatment of high-grade AIN in routine care for people living with HIV. Treating high-grade AIN could help prevent cases of anal cancer that would be much harder to treat later on. However, resources, like screening equipment and trained staff, are often limited and many people currently don't have access to screening. More clinicians need to be trained to perform a procedure called anoscopy to make screening more widely available.
When you go to a screening appointment or if you have an appointment because you're experiencing any symptoms, a first check could be a rectal examination. This involves your doctor inserting a gloved finger into your back passage to feel for any lumps or swellings. This is usually quick and painless.
Glossary cancerA collection of related diseases that can start almost anywhere in the body. In all types of cancer, some of the body's cells divide without stopping (contrary to their normal replication process), become abnormal and spread into surrounding tissues. Many cancers form solid tumours (masses of tissue), whereas blood cancers such as leukaemia do not. Cancerous tumours are malignant, which means they can spread into, or invade, nearby tissues. In some individuals, cancer cells may spread to other parts of the body (a process known as metastasis).
anal intraepithelial neoplasia (AIN)An abnormal growth on the surface of the rectum or anal canal which, when observed with a microscope, suggests that the cells could be malignant (cancerous).
human papilloma virus (HPV)Some strains of this virus cause warts, including genital and anal warts. Other strains are responsible for cervical cancer, anal cancer and some cancers of the penis, vagina, vulva, urethra, tongue and tonsils.
symptomAny perceptible, subjective change in the body or its functions that signals the presence of a disease or condition, as reported by the patient.
radiotherapyA medical treatment using radiation (also known as radiation therapy). Beams of radiation may be produced by a machine and directed at a diseased area from a distance. Alternatively, radioactive material, in the form of needles, wires or pellets may be implanted in the body. Many forms of cancer can be destroyed by radiotherapy.
You can also do a self-exam to check for anal lumps. This is called a Digital Ano-Rectal Examination (DARE). This can help you detect lumps when they're smaller and easier to treat. You can find more information on how to do this exam on yourself or your partner on the Body Positive New Zealand website.
Your doctor may also recommend an anal swab (also called anal smear test). For this, your doctor will pass a small swab just inside your anus to collect cells, which are suspended in fluid, stained and examined under a microscope (a process called cytology). This is usually quick and painless. The swab can also be used for an HPV test to check to see if you have a type of HPV that increases your risk for anal cancer. This is not enough to diagnose AIN or anal cancer but can be used as a first check. Or it can be used to check for AIN.
A different technique to check for AIN is anoscopy. Its results seem to be more accurate in people living with HIV than the smear test. A small magnifying device is inserted into the anus in order to visually examine the cells of the anal canal. This should take a few minutes and is not painful.
If necessary, a biopsy will be taken during the anoscopy. Tiny samples of tissue are removed under local anaesthetic, which numbs a small part of the body, to minimise any discomfort. These cells will then be examined under the microscope to check if they are normal cells, abnormal cells or cancerous cells. This is called a histology.
Other examinations can include proctoscopy, which is similar to anoscopy but can also examine the rectum. Again, biopsies may be taken of what seems to be abnormal tissue. This is necessary to check if cells are cancerous.
If you have anal cancer, you will need further scans to find out more about the position of the cancer and to see if it has begun to spread. These include a CT (computerised tomography) scan and an MRI (magnetic resonance imaging) scan.
Treatment and managementIf you have low-grade AIN, no treatment is needed. You may be asked to come back in six or twelve months for another screen.
If you have high-grade AIN, one of the following treatments may be offered:
You may experience some side effects when you receive treatment for AIN, for example skin irritation, pain and bleeding.
None of these treatments has a 100% success rate – in many cases, the problem recurs. This may be because the treatments do not get rid of the underlying HPV infection.
If you have anal cancer, the recommended treatment is chemoradiotherapy. This is a combination of chemotherapy and radiotherapy, usually over a period of five weeks. Chemotherapy uses strong drugs to destroy cancer cells and prevent the cancer from spreading. Radiotherapy uses beams of radiation to destroy the cancer cells, in a localised area only.
Chemoradiotherapy is usually successful but does sometimes cause long-term complications. These can include problems in relation to your bladder, bowels and sexual function.
If chemoradiotherapy doesn't get rid of all the cancer or if there are signs that it has come back, surgery may sometimes be used.
The same types of treatment are used for people with HIV and people without HIV. The treatment you are offered shouldn't be different to that of other people just because you have HIV.
It's recommend you continue to take HIV treatment during your cancer treatment, or if you haven't already, that you start. Taking HIV treatment during cancer treatment is associated with living longer and a lower risk of opportunistic infections. Chemotherapy and radiotherapy both suppress the immune system, which may result in a significant drop in your CD4 count. You should be given drugs to prevent opportunistic infections (this is known as prophylaxis). Your CD4 count may be checked more often after cancer treatment than it would be normally.
There can be drug-drug interactions between cancer treatments and HIV treatments. For this reason, it may be necessary to make some adjustments to your HIV treatment or your cancer treatment.
As treatments for HIV and cancer can both cause side effects, your doctors should keep an eye on how they are affecting you. In some cases (such as nausea from chemotherapy), highly effective treatments to limit side effects are now available. If side effects become too severe, your doctors may need to adjust one of the treatments. We recommend you speak to your doctor if you're worried about side effects of your treatment.
You need to see specialist doctors for the monitoring and treatment of both AIN and anal cancer. Depending on where you are, your local hospital may not have the necessary experience in this area. It's very important that the doctors treating your cancer and your HIV work together. There should also be contact between the pharmacists in the cancer and HIV clinics.
A multi-disciplinary team will make recommendations about your treatment. This team may include an oncologist (a doctor who specialises in treating cancer), a radiologist (a doctor who interprets the results of scans or provides radiotherapy) and a pathologist (a doctor who examines tissue for cancer cells). You will be supported by a cancer specialist nurse during your cancer journey. If a cure is not possible, palliative care can relieve pain and other symptoms and help you maintain the best possible quality of life.
Information and supportFor more information, you may find the website of Macmillan Cancer Support helpful: www.Macmillan.Org.Uk. In the UK, you can also contact their helpline team on 0808 808 0000.
For more information on cancer organisations around the world, you may find helpful links on the International Cancer Information Service Group website or on the American Cancer Society website.
Human Papillomavirus (HPV) And Genital Warts
Key pointsThe human papillomaviruses (HPV) are a family of over 100 strains of virus. About 30 different HPV strains can affect the genital area. These strains can also affect the mouth and throat.
HPV is a very common sexually transmitted infection (STI). Most people will get some type of HPV in their life time. Some strains of HPV can cause genital warts or cancers, while others may not do any harm or cause symptoms. There are especially high rates in young people, although vaccination against HPV for young women has reduced numbers of infections significantly. Young gay men have been found to have particularly high rates of anal HPV in some research. Having HPV has also been linked to a higher risk of becoming infected with HIV in some research.
Some strains of HPV can lead to cervical or anal cancer. The risk of this is higher in people with HIV because there is more chance that the virus will become re-activated due to loss of immunity, although both cervical and anal cancer are relatively rare in people with HIV. Very rarely, high-risk types of HPV can also cause vulval, vaginal, penile and some mouth and throat cancers. Being on HIV treatment, with an undetectable viral load, and having a higher CD4 cell count (certainly over 200) can reduce the risk of developing HPV-related cancers.
TransmissionHPV can be contracted during unprotected anal, vaginal or, rarely, oral sex. It can also be passed on through other skin-to-skin contact with the genital area or by sharing sex toys, even if the partner doesn't have any genital warts. It is possible to have more than one strain of HPV at any time.
It is possible for a mother to pass HPV on to her baby during delivery, but this is rare.
PreventionUsing a condom for anal, vaginal and oral sex offers a degree of protection from infection with HPV, or from passing on the virus to somebody else. However, protection isn't complete as the skin around the genital area may also carry the infection. Don't share sex toys; if you do, cover them with a condom or wash them between uses.
People who are sexually active are advised to have regular sexual health check-ups, especially if you have recently had a new partner. It is recommended that people with HIV have a sexual health check at least once a year. There you can be examined for genital warts and get tested for other sexually transmitted infections. In some situations, having a check-up more often may be recommended, such as if you are having unprotected sex with new or casual partners. Gay men having unprotected sex – including oral sex – with new or casual partners are advised to have a sexual health check every three months.
In the UK, most HIV treatment centres have an associated sexual health clinic where free and confidential treatment can be obtained without referral from your GP or your HIV doctor.
Three vaccines are available that offer protection against certain strains of HPV, including those that have the highest risk of leading to cervical or anal cancer. All three can offer protection against HPV strains 16 and 18, which cause 70% of cervical cancers and 80% of anal cancers worldwide. Two of the vaccines are also effective against types 6 and 11 which do not cause cancers but cause most of the genital warts.
Vaccination is likely to have the greatest benefit before young people become sexually active. If you have already been exposed to the HPV types covered by the vaccine, being vaccinated will not reduce the risk of future disease caused by HPV.
In the UK, the National Health Service (NHS) recommends two doses of vaccination for people under the age of 15 and three doses for those above 15. In the UK, USA, Australia and some other countries there are vaccination programmes for girls and boys at schools. It is also possible to pay to have the vaccination as a private patient. If you are considering this, make sure that you talk to your HIV doctor and have a blood test to see if you are already infected with the strains of HPV the vaccine protects against.
The European AIDS Clinical Society (EACS) and the British HIV Association (BHIVA) recommend vaccination for everyone living with HIV under the age of 26, and for all gay men up to the age of 40.
SymptomsMost strains of HPV do not cause obvious symptoms, so people may not realise they have the infection.
Glossary human papilloma virus (HPV)Some strains of this virus cause warts, including genital and anal warts. Other strains are responsible for cervical cancer, anal cancer and some cancers of the penis, vagina, vulva, urethra, tongue and tonsils.
cervixThe cervix is the neck of the womb, at the top of the vagina. This tight 'collar' of tissue closes off the womb except during childbirth. Cancerous changes are most likely in the transformation zone where the vaginal epithelium (lining) and the lining of the womb meet.
strainA variant characterised by a specific genotype.
cancerA collection of related diseases that can start almost anywhere in the body. In all types of cancer, some of the body's cells divide without stopping (contrary to their normal replication process), become abnormal and spread into surrounding tissues. Many cancers form solid tumours (masses of tissue), whereas blood cancers such as leukaemia do not. Cancerous tumours are malignant, which means they can spread into, or invade, nearby tissues. In some individuals, cancer cells may spread to other parts of the body (a process known as metastasis).
vaccineA substance that contains antigenic components from an infectious organism. By stimulating an immune response (but not disease), it protects against subsequent infection by that organism, or may direct an immune response against an established infection or cancer.
Most cases of visible genital warts are caused by strains 6 and 11. They can take up to a year to develop after infection takes place. The warts can look and feel much like those that may appear on other parts of the body – small nodules with either a smooth or rougher texture. They can appear singly or in 'cauliflower'-like clusters. They are usually painless, but can become itchy or inflamed. Occasionally they may bleed. If left untreated genital warts may resolve spontaneously, remain unchanged, or increase in size or number.
Warts may appear on the inside or outside of the vagina, on the neck of the cervix, in or around the anus and on the thighs. Genital warts may also appear on the tip or shaft of the penis, on the scrotum or on the urethra.
DiagnosisFor women, cervical screening (a smear test) is used to detect pre-cancerous cellular changes called dysplasia early, before cancer develops. A small sample of cells from the cervix are examined under a microscope, to see if there are any changes in the cells which suggest a risk of cervical cancer developing in the future.
HIV-positive women are recommended to have cervical screening when they are first diagnosed with HIV, six months later, and then at least once a year. Trans men who have had a total hysterectomy to remove their cervix do not need cervical screening.
The value of regular screening of the anal canal for pre-cancerous cells is less clear, and it is not currently recommended as standard, although some clinics offer it. You may want to ask about screening, especially if you have already had anal warts.
Genital warts are diagnosed by visual and manual examination of the genital and anal area.
TreatmentIn most cases, the immune system naturally clears infection with HPV. The average length of any single anal HPV infection is five months to a year. People with weaker immune systems may take longer to get rid of it.
In some cases, the infection persists and can cause other health problems, such as warts and cancers.
If you have visible warts, there are several treatments, none of which cure HPV. Treatment can involve applying topical creams or liquids, freezing, laser treatment or surgery. These procedures may feel a little uncomfortable; for some, you will have a local anaesthetic. Sometimes treatment will need to be repeated, or a combination of different methods used. For reasons that are not fully understood, treatments are more effective in people who do not smoke. If you smoke, you may want to consider giving up before you start treatment for genital warts.
HPV vaccination is not effective against current infections.
If screening shows that you have developed pre-cancerous cells in your cervix or anus, there is treatment available. If detected early, treatment for these changes is very effective.
HPV: The Need To Confront Men's Anal Health
These conditions are often accompanied by a foul odor due to secondary infections, leaving patients feeling stigmatized and isolated.By SAMUEL ANYULA
As Kenya approaches World AIDS Day 2024 with its focus on promoting the health and well-being of men and boys, it is crucial to address a silent epidemic that has been largely overlooked—human papillomavirus (HPV) outbreaks among men. Although many variances of HPV are cleared by a healthy immune system, a number of HPV genotypes found to be prevalent in African contexts (including Kenya) can cause ano-genital warts and cancers.
As an HIV clinician with more than 5 years of experience working in a community-led men's clinic, I have encountered men presenting with severe, advanced HPV-related symptoms that are both physically and emotionally distressing. Some patients arrive with massive, cauliflower-like anogenital warts that obstruct normal bodily functions, causing intense pain, bleeding, and difficulty in sitting or walking. These conditions are often accompanied by a foul odor due to secondary infections, leaving patients feeling stigmatized and isolated. Many expressed a deep sense of shame, admitting that they delay seeking care due to stigma and a lack of knowledge and fear of judgment [9]. These experiences underscore the urgent need for increased awareness, comprehensive education, and a supportive men-centered HPV care—both with respect to prevention and treatment.
For a long time, HPV has been mischaracterized as solely a women's health issue. Consequently, men, particularly those at increased risk and living with HIV, have been left out of HPV prevention campaigns. These include awareness creation, screening and early detection, vaccination, and even treatment within the frameworks of HIV programs. This exclusion has led many men to seek care only when they present with advanced stages of HPV-related diseases, which increases the risk of malignancies and the potential progression to various forms of cancer, such as anal, penile, and throat cancer.
For too long, men's health has been sidelined in the HIV response, leading to missed opportunities for early intervention and holistic care. The high correlation between HPV and HIV in men, especially men living with or at heightened risk for HIV, demands urgent attention. If strides are to be made in HIV prevention, care, and treatment, as well as STI programs, integrating comprehensive HPV screening and vaccination into both HIV programs and general health services for young men must become a priority.
A 2023 research study conducted in Nairobi County highlighted the high risk of HPV infection among men living with HIV, male sex workers, and other key populations [8]. Half were found to have an HPV infection. Among those infected, 84% had an HIV-positive status. HPV samples revealed the presence of high-risk strains, such as HPV-16, which is highly associated with penile, anal, throat, and cervical cancers. Importantly, many of the carcinogenic HPV variances are preventable with the vaccines currently available in the country. However, in our public facilities these vaccines are freely available, and therefore largely accessible only to adolescent girls and young women (AGYW).
According to the Anal Cancer Foundation, HPV causes 5% of all cancers worldwide, including a majority of anal (91%), cervical (91%), mouth and throat (70%), vaginal (75%), vulva (69%), and penile cancers (63%). However, early detection and vaccination programs can ameliorate these preventable cancers. Since the HPV vaccine's global introduction in 2006, there have been significant reductions in HPV-related cancers. Australia's gender-neutral vaccination program, which included both boys and girls, resulted in a sharp decline in HPV infections. A Swedish study also showed a reduced genital warts with a more than 25% reduction among females age 17 to 18 years. Additionally, a meta-analysis of 65 papers across 14 countries found decreases in anal and genital warts by almost half in boys aged 15–19, and 32% in men aged 20–24 within five to eight years of the vaccine rollout. These statistics underscore the vaccine's impact in averting millions of HPV-related cancers globally.
Some may argue that including men and boys in HPV screening and vaccination programs would strain already limited resources and divert vaccines currently targeting AGYW. On the contrary, investing in these preventive measures now can reduce long-term healthcare costs associated with treating advanced HPV-related conditions. For example, between 2016 and 2019, a total of 239 men in Nairobi underwent surgery at the clinic where I work, with 72 experiencing a recurrence that required additional surgical intervention. These procedures cost the clinic more than £60,000 over the four-year period. Also investing in awareness raising, demand creation, and provider training can educate men on HPV risks, increase vaccine and screening uptake, and equip healthcare workers with necessary skills. These efforts can prevent advanced HPV-related conditions, saving lives and reducing long-term healthcare costs.
This year even after the World AIDS Day, we must emphasize men's health; we must push for a more inclusive HIV response that recognizes the critical intersection of HPV and HIV. Policymakers, healthcare providers, and funding agencies must work together to ensure HPV screenings and vaccination become standard components of HIV care for men and boys at heightened risk. Let's make some noise and finally expose and confront the silent epidemic of HPV among men.
Samuel Anyula Gorigo is an AVAC Fellow and healthcare provider based at HOYMAS medical center in Nairobi, Kenya
Comments
Post a Comment