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Long delay time in anal Papanicolaou follow-up of HIV patients

 


Those who received an abnormal anus took an average of 380 days Pap test Results after being diagnosed with HIV Have a high resolution anoscopy (HRA) recommended as a follow-up.

Dr. Jessica Wells, a research assistant professor at Emory University’s Nerhodison Woodruff Nursing School in Atlanta, Georgia, said the delay “missed an opportunity for a better experience at the patient, clinic, and healthcare provider level.” I did it. ” Medscape Medical News.. After all, she said, “Many things can happen in the year.” Human papillomavirus (HPV) related Anal cancer..

It’s too early to say how important that delay is to the natural history of anal cancer, but Wells said the data are a potential signal of inequality.

“The results of my study may foresee potential inequality if the resources needed to promote follow-up care after the abnormal Papanicolaou trial are not in place. Cervical cancer“She said at the 2020 Annual Meeting of the Virtual AIDS Care Nurses Association (ANAC).

Single-center study

In the United States, people living with HIV 19 times more likely According to a 2018 article, it develops anal cancer more than the general public Journal of Clinical Oncology..another Single-center study Researchers at Yale University have found that the minority community has a 75% higher incidence of anal cancer than the white community. The incidence of anal cancer was 72% higher in poorer areas. as a result, Many clinics We are starting a Papanicolaou trial to determine the early signs of HPV infection and related changes.

A 2012-2015 Wells study recruited 150 adults with HIV over the age of 21 from the Grade Ponce Deleon Center in Atlanta.according to 2018 study From that center, the majority of participants were infected with late-stage HIV and suppressed the immune system.

After the recent abnormal anal Papanicolaou test, all participants were referred to HRA. Participants completed a questionnaire on socio-demographics, internalized HIV-related stigma. depression, Risk behavior, social support, and knowledge of HPV and anal cancer.

Participants were disproportionately older (mean age 50.9 years), cisgender (86.7%), black (78%), gay, lesbian, or bisexual (84.3%). One in ten (11.3%) of the participants were transgender women.

For 6% of participants, the results of the Papanicolaou trial showed high-grade squamous intraepithelial lesions (HSIL), while an additional 8% showed atypical Papanicolaou findings for which HSIL could not be ruled out. This is a kind of result that is one step away from cancer diagnosis. Over 80% of participants showed low grade or inconclusive results. Almost half (44%) of the participants’ Papanicolaou trial revealed low-grade squamous intraepithelial cell lesions (LSIL). 42% showed atypical squamous epithelial cells of unknown importance.

When Wells investigated how long the participants were waiting for the HRA, she found something that surprised her. Some participants were followed up in 17 days, but often took a much longer time. The longest waiting time was 2350 days, more than 6 years.

“There were quite a few patients who received more than 1000 days of follow-up,” Wells said. Medscape Medical News on mail. “I didn’t think the delay was that long. At best, the patient would be scheduled and would be back within weeks or months.”

In addition, through the HPV Knowledge Questionnaire, she found that many participants did not understand why they were planning to follow up. Anecdotally, some people confuse HPV with HIV.

“People living with HIV have education to inform this target population that the virus is more likely or at higher risk to cause cancer later,” she said. “There are many campaigns around women living with HIV and we need to screen for cervical cancer. I think we really need to expand this campaign to include that HPV can also cause anal cancer. I will. “

Wells planned to primarily investigate the impact of psychosocial factors on wait-up time to follow-up, but none of these factors were associated with longer wait times.

System level factors

That’s why Dr. Anne Gakumo, Dean of Nursing at the University of Massachusetts Boston School of Nursing and Health Sciences in Boston, Massachusetts, asked what other factors were causing the delay.

There were some, Wells said. Unstable homes, for example, may have influenced this delay in follow-up. About one in four participants reported that they lived in temporary housing and one participant was imprisoned. She will collect addresses and analyze the data to see if a case has occurred in a particular neighboring cluster, as data from Yale University shows.

In addition, the anoscopy clinic was able to accept patients only one day a week and had only one clinician trained to perform HRA. The wait time can be hours. From time to time, participants had to leave the clinic to attend other businesses, and their appointments had to be rescheduled, Wells said.

In addition to the lack of understanding of the importance of follow-up testing, Wells “is beginning to see these barriers overlapping.

“That’s where we start seeing breakdowns,” she said. “So I hope that larger studies can address some of these barriers with a multi-level approach.”

This resonated with Gakuun.

“Often we put much of the responsibility for this on the client side, not on the provider side or at the system level,” she said.

Guidance guidelines

There are few guidelines for follow-up of abnormal anal Papanicolaou test results. This is primarily due to the unestablished natural history of HPV-related anal cancer, unlike cervical cancer. HIV Medical Association It is recommended Anal Papanicolaou test. However, only if “access to appropriate referrals for follow-up, including high-resolution anoscopy, is available.”

In an interview with Medscape Medical News, Cecil Lahiri, MD, MD, an assistant professor of infectious diseases at Emory University, said the Ponce de Leon Center would recommend anal Papanicolaou to HIV women with a history of cervical dysplasia.

Although there is a reliable link between the high-grade abnormal Papanicolaou test and cervical cancer, low-grade changes can resolve themselves. Mild cellular changes are predicted for anal cancer, especially in HIV patients. In addition, for such patients, anal cancer is more likely to recur and is difficult to treat, Lahiri said.

“The cervical and anal environments are very different,” said Lahiri, who worked at the Gradypons Deleon Center but was not involved in Wells’ research. Lahiri is also a multi-site, randomized, control collaborator Anal Cancer HSIL Outcome Research (ANCHOR) A study that seeks to establish whether early treatment of high-grade anal Papanicolaou changes is superior to a follow-up approach.

Lahiri said that the availability of the results of the study would increase the likelihood of knowing how important early anoscopy and treatment are. The findings should provide information on anal Papanicolaou test and anoscopy guidelines and insurance coverage.

Meanwhile, she said she suspected that the 2015 ANCHOR trial might have increased the capacity of many sites for anoscopy and reduced waiting times.

“One of the most important parts of the study is the period in which it was actually performed,” said Lahiri, who became the second doctor in the clinic trained in anoscopy in 2015. Currently, more than 200 people at the Ponce de Leon Center are enrolled in the ANCHOR trial. In addition, the results of the trials have improved the general ability to perform anoscopy nationwide, requiring more healthcare providers to learn how to properly perform HRA. According to Lahiri, many clinicians, such as gastroenterologists and surgeons, are not regularly trained to perform HRA.

“It would be interesting to see the difference that ANCHOR starts before and after,” she said.

AIDS Care Nurses Association (ANAC) 2020 Annual Meeting: Summary LB-4. Announced on November 12, 2020.

Heather Boerner is a science and medical reporter based in Pittsburgh, Pennsylvania. Her book, Positively Negative: Love, Sex, and Science’s Surprising Victory Over HIV, was published in 2014.

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