HIV AND THE ANUS

M62 Coloproctology CourseApril 2005

Mr P Mullerat, FRCS Prof M C Winslet, MS, FRCS

Royal Free and University College Medical SchoolLondon

HIV – AIDS

• Epidemiology

• Common anal pathology

• Chlamydia• HPV• Herpes

HIV epidemiology

• 42 million people are HIV + worldwide

• 65000 HIV + in UK

HIV epidemiology

• 42 million people are HIV + worldwide

• 65000 HIV + in UK7000 new cases/year

57% acquired by MSM practices

Highest incidence in SE England

ANORECTAL PATHOLOGY

• 5% of HIV/AIDS patients are referred to the proctologist

ANORECTAL PATHOLOGY

• 5% of HIV/AIDS patients are referred to the proctologist

• Common symptoms:• Pain (55%)• Mass (20%)• Bleeding (15%)

ANORECTAL PATHOLOGY

• 5% of HIV/AIDS patients are referred to the proctologist

• Common symptoms:• Pain (55%)• Mass (20%)• Bleeding (15%)

• 1/3 will require surgical intervention

INITIAL MANAGEMENT

• Multidisciplinary approach. GUM and AIDS specialists

INITIAL MANAGEMENT

• Multidisciplinary approach. GUM and AIDS specialists

• Understand homosexual intercourse

INITIAL MANAGEMENT

• Multidisciplinary approach. GUM and AIDS specialists

• Understand homosexual intercourse

• Reinforce safe sex

INITIAL MANAGEMENT

• Multidisciplinary approach. GUM and AIDS specialists

• Understand homosexual intercourse

• Reinforce safe sex

• High resolution anoscopy• Gonorrhoea and Chlamydia screening• HSV, Syphilis, HPV screening if ulcers or fissures

COMMON PATHOLOGY

HIV related

• Condylomata 49%• Anal ulcers 35%• Herpes lesions 3%

Non HIV related

• Abscess-Fistula 35%

• Fissure 32%• Haemorrhoids 6%

ANAL HERPES

• Aetiology– HSV – 1 (10%)– HSV – 2 (90%)

• Symptoms– Irritation– Vesicles– Ulcers – Intense pain

• Treatment– Acyclovir– Vidarabine

ANORECTAL CHLAMYDIA

• Symptoms– Tenesmus, proctitis, discharge– Anal ulcers – Lymphogranuloma venereum (LGV)

Inguinal lymph nodes with erythema

• Treatment: Tetracycline

HUMAN PAPILLOMAVIRUS

• Epidemiology

• Natural history

• Host’s response

• Management and screening

EPIDEMIOLOGY

High risk populations

• Homosexuals• Females with Hx of CIN/cervical SCC• Partners of above• Post-transplant• HIV +

HPV EPIDEMIOLOGYINCIDENCE OF ANAL SCC

7 9

350

700

0

100

200

300

400

500

600

700

800

males females HIV - HIV +

overall MSM

1/p

er 1

0^6

po

pu

lati

on

Incidence of anogenital condylomata in UK Incidence of anal SCC in San Francisco

Communicable Disease Report, Vol 9, 44. 1999 J. Palefsky et al, J Infect Dis, 183, 3. 2001

NATURAL PROGRESSION

Warts 10%

AIN I 10%

AIN II 10%

AIN III5-10%

Similar behaviour as CIN Anal SCC

CONDYLOMATA

? AIN

? SCC

ROYAL FREE STUDY

Relationship between

• Local immune response• Oncogenic HPV exposure

and progression to AIN and SCC?

METHODS

HPV EXPRESSION

HPV DNA typing using SPF and LiPA PCR

IMMUNE RESPONSE

Density of stromal and epithelial lymphocitic infiltration, using CD3, CD4 and CD8 antibodies

• Retrospective study (1989 -2001) • 82 patients (42 HIV – and 40 HIV +)• Paraffin sections

Patients

HIV –

– Warts 12– LG-AIN 2– HG-AIN 10– Anal SCC 12– Controls 6

HIV +

– Warts 10– LG-AIN 11– HG-AIN 13– Anal SCC 0– Controls 6

LYMPHOCYTIC INFILTRATE

CD4+ expression CD8+ expression

HG AIN in HIV + (x250)

RESULTS

HPV EXPRESSION

Carcinogenic HPV DNA

0.00

20.00

40.00

60.00

80.00

100.00

120.00

Skin Warts LG-AIN HG-AIN SCC

% H

PV

exp

ress

ion

HIV-

HIV+

p>0.05

LOCAL IMMUNE RESPONSE

EPITHELIAL INFILTRATE IN HIV - & HIV+

0

5

10

15

20

25

30

35

lym

ph

ocy

tes

/ 100

ep

ith

elia

l cel

ls

CD3

CD4

CD8

*

*

*

**

*

STROMAL INFILTRATE IN HIV - & HIV +

0

50

100

150

200

250

300

350

10^3

cells

/ m

m2

CD3

CD4

CD8*

*

*

**

*

*

*

* * * **

*

*

*

*

* p<0.05

Conclusion

Factors of disease progression in HIV+ is the poor local immune response.

Oncogenic HPV are expressed in 100% of HG-AIN and anal SCC. No difference between HIV + and HIV - groups

Management of anal HPV

• Early detection – Risk populations

• Accurate staging High resolution anoscopy

• Cytology – liquid based• HPV PCR

• Markers of progression• local CD4-CD8