There is some misinformation about our practice regarding screening and treatment of HPV-related anal disease that is floating around on social media. This information is false and harmful to our community. I wanted to take this opportunity to set the record straight and provide an update regarding HPV-related anal disease, as it is a very serious issue facing the gay community.
This is a detailed update, so please hold tight as I brief you on other important issues as well.
Anal Cancer Screening & Treatment
The incidence of anal cancer continues to increase. It is estimated this year that 8,300 people will be diagnosed with anal cancer in the United States. The highest risk group to get anal cancer is men having sex with men (MSM).
HIV-positive MSM have a 1 in 100 chance of getting anal cancer in their lifetime, while the prevalence rate in HIV-negative MSM is 37 in 1000.
This cancer is caused from the most common STD called human papilloma virus (HPV). Almost all MSM get exposed to this early in their sex life. Most strains of HPV that cause cancer and warts can be prevented by receiving Gardasil, a simple three step vaccine. There is some good news in that the FDA just approved it up to 45 years of age! We are waiting now for insurance to begin paying for it and we will let you know as soon as they do.
Anal Pap Screening
Many of you have had or will have an abnormal pap smear. This lesson will help you further understand the process of screening and treatment.
The following recommendations are for MSM; however, women get anal cancer too, and their incidence is increasing. Farrah Faucet became the face of anal cancer about 10 years ago, and now Marcia Cross is sharing her story about it as well. Women are rarely getting screened, and since their incidence is lower, we are still trying to figure out which group(s) of women should be screened.
Anal pap screenings are just that – a screening test! Certainly, no screening is perfect. Anal cancer screening is not currently recommended for the general population, but it is recommended for high-risk populations, such as gay men, especially those with HIV.
It is estimated that the sensitivity of the pap to pick up atypical cells ranges from 46 to 69 percent in MSM with HIV. Specificity of the test ranged from 59 to 81 percent. In HIV-negative MSM, the sensitivity of the pap ranged from 26 to 47 percent and specificity ranged from 81 to 92 percent. Simply put, a negative pap is no guarantee that there are no atypical or pre-cancerous cells. However, a positive Pap smear warrants further evaluation, and a negative pap in those who are high-risk (i.e. MSM, HIV-positive MSM) should be followed with regular screening. More on this below…
Based on the lower sensitivity, or the ability, of the pap to pick-up abnormal cells, it is completely possible, for example, for someone to have an atypical pap today but it be completely normal on repeat next week. However, this is currently the best screening process we have.
We adhere to the guidelines published by the IANS (International Anal Neoplasia Society). First of all, an anal pap smear and a special digital exam called DARE (digital anal rectal exam) is the first step in screening for anal cancer. This should be done at your physical exam.
If your pap smear is normal, repeat pap smear is recommended every three years. If your pap smear is abnormal, further screening is recommended.
For an abnormal pap smear, a high-resolution anoscopy (HRA) is recommended. The HRA is a test that looks at the anus with an anoscope under a special microscope using two stains.
Let’s go over the different degrees of abnormal pap smears:
ASCUS– atypical cells of undetermined significance, meaning the cells are abnormal but not definitely precancerous.
LGSIL– low-grade precancerous cells
HGSIL– high-grade precancerous cells
A biopsy during the HRA exam is required for any suspicious lesion seen. Lesions like this are rare in ASCUS but more common in LGSIL and HGSIL.
Anal biopsies have their own classifications and carry more significance than the pap smear because it is the examination of the actual anal tissue itself by a pathologist.
There are different categories of results of anal biopsies:
AIN I low grade precancerous cells
AIN II moderate grade precancerous cells
AIN III severe grade precancerous cells
Carcinoma in situ-an early noninvasive cancer
Any precancerous lesion, AIN II or greater, is treated most commonly using an infrared coagulator (IRC). This is what our clinic uses. This instrument gives very short burst of infrared light to precisely treat tissue where an abnormal biopsy was taken.
An IRC is also used to ablate anal warts. Both treatments of precancerous lesions and warts are done in our office.
All abnormal pap smears and abnormal biopsies are followed with repeat pap smears and/or HRAs, with different frequencies specific to each category, until clear.
Unfortunately, there aren’t many practices in the United States that perform HRAs. In fact, it is estimated there are only about 50 practices in the country who perform this procedure. However, it is the standard-of-care to screen and treat this disease!
I first trained in HRA/IRC over 10 years ago at a time when there were no good treatment protocols or anyone doing HRAs in Atlanta.
I was trained by Dr. Joel Paleskfy, a world expert at the University of California in San Francisco. I then completed an internship in Chelsea, New York with Dr. Stephen Goldstone, former president of the (IANS) International Anal Neoplasia Society.
My colleague, Dr. T.C. Elliott was trained on HRAs during his residency at Harvard. Harvard has a residency program with training specific to the needs of the LGBT community. This, of course, includes HPV anal disease.
Again, we follow the guidelines from the IANS, and I remain an active member in the society.
Anal Cancer Screening is Important
I know screening and treatment of anal pre-cancer is not a fun exercise. It may be a little awkward and uncomfortable, but it is so important! Women have had similar protocols and have had to endure the same type procedures of the cervix for many years. To be frank, we need to get over it and just have the screenings and exams done. Again, it is the best way we currently have to screen for and treat anal cancer.
Unfortunately, we diagnose anal cancer in new patients that have never had pap smears or never received the Gardasil vaccine. It is heart breaking to watch these patients have to go through the treatment, which includes radiation to the anus, an organ that not only serves a function of digestive tract but is also a sexual organ for MSM.
The two main faces of anal cancer I mentioned are women, but a brave gay man named David shared his story on YouTube. If you would like to hear a story from a gay’s man perspective, which I hope will give you insight into why our team will do everything possible not to let this happen to you, please watch David’s story.
Updates on HIV and STIs
I recently returned from attending the STI and HIV World Congress meeting in Vancouver, Canada. Yes, you probably don’t even want to know how scary the STI world is now, but I am going to tell you anyway!
In the past year, I have also attended the International AIDS conference in Amsterdam, the New York HIV course, and the Internal Medicine update at University California San Francisco.
Here are the updates:
Fulton County has one of the highest new diagnosis HIV rates in the country. Even with PrEP, new diagnoses continue to increase. There are 40,000 new cases a year in the US, 51 percent in the South and 70 percent MSM.
U = U
Undetectable equals untransmittable. No person with HIV on medication with undetectable viral load can transmit HIV to someone period. I love saying that and it is time to stop the stigma!
Injectable medication should be available in about 18 months. You will have the option to receive an injection once a month instead of taking pills every day.
Descovy will be approved for PrEP in the very near future. It will have less kidney and bone toxicity.
But there is more. In about 18 months, an injectable PrEP will also be available to take every two months. Down the road there will be implants and infusions of antibodies that will give longer durations of protection.
We will be sure to keep you updated!
With the era of PrEP and people not using condoms as much anymore, there is a lot changing in the world of STIs. Neisseria Meningitis has been “in bed” with Neisseria Gonorrhea in the throat. They have exchanged genes and now N. Meningitis is infecting the throat and penis. More interestingly, the vaccine Bexsero, which a lot of you have had to protect against Meningitis, is giving protection against Gonorrhea. Very fascinating!
Also, we know that the throat and saliva is the key in transmitting gonorrhea. Gonorrhea is transmitted 75 percent by kissing/saliva. That means it is much safer to give oral sex than to kiss someone regarding Gonorrhea. Also, men who aren’t using condoms may also not be using lube and instead are using spit for lubrication. This is leading to them giving their recipient gonorrhea in the anus. Listerine kills gonorrhea. Gargling one minute each day with alcohol based Listerine will prevent most cases of Gonorrhea. It is modeled that if 75 percent of gay men gargled 75 percent of time daily we could eradicate it from MSM community.
Resistance and Emerging STIs
Gonorrhea is becoming resistant to current treatments. The US committee met this summer and new guidelines for treatment are expected anytime now. Most countries have already adjusted their treatment guidelines.
Some STIs are becoming more common. These include Mycoplasma genitalum which is infecting the penis, and LVG
(lymphogranuloma venereum) which is causing proctitis.
Also, Hepatitis C infections have increased. This is not from semen, as we were questioning in the PReP barebacking era, but instead caused from contact with blood. Contact with blood is common in certain sexual practices, including fisting, using toys, snorting drugs, aggressive douching before sex, and is especially more common in group sex settings. Hepatitis C can live 16 hours on surfaces!
On the Frontlines
There is a lot happening in the healthcare arena in the LBGT arena. Our mission is to be there on the frontline giving you the best, most up-to-date evidence based healthcare available. This care required is very different from the mainstream care. Unfortunately, you can’t get it at a regular medical clinic. They just don’t know about it and, honestly, don’t care to keep up with it.
We have an amazing team of providers in our practice with Dr. Elliott, Forrest, and Jeremiah! We are about to add another doctor to our practice, as Dr. Stephen Powell will be joining our team this October! More to come about him soon.
I want to close on one more note. We all realize that healthcare coverage is in a really bad state and getting worse each year in our country. It is not good for the patient and is not good for us as providers. I surely don’t have the answers or solutions to fix it. I’m not sure anyone does. Every year deductibles and patient responsibilities increase. The red tape involved in getting treatment approved is beyond ridiculous. We waste so much time every day getting ordinary medications approved. But, what I do know is we are there for you, we truly care for you, and we strive to keep you healthy.
Dr. Doug Gurley is an Atlanta based Board Certified Internal Medicine physician and HIV specialist who has been practicing LGBT healthcare for over the past 20 years.