Why are we not screening for anal cancer routinely - HIV physicians’ perspectives on anal cancer and its screening in HIV-positive men who have sex with men: a qualitative study

BACKGROUND: Anal cancer is a priority health issue in HIV positive men who have sex with men. Anal cancer screening may be aimed at either detecting the precursor lesion (high grade anal intraepithelial neoplasia(HGAIN)) or early anal cancer. To date no qualitative study has explored the views of HIV physicians regarding anal cancer and its screening. METHODS: We conducted indepth interviews with 20 HIV physicians (Infectious diseases, Immunology, Sexual health, General practice) in different settings (hospital, sexual health centres, general practice) from around Australia. Framework analysis was used to identify themes. RESULTS: HIV physicians viewed anal cancer as a significant health issue and all agreed on the importance of anal cancer screening amongst HIV positive MSM if a valid screening method was available. Barriers for utilizing anal cytology was based primarily on the theme of insufficient evidence (e.g. no studies demonstrating reduction in mortality following screening or effective treatments for HGAIN). Barriers for utilizing DARE for early cancer detection were based on systemic factors (e.g. lack of opportunity, lack of priority, differences in HIV care practices); health provider factors (lack of evidence, difficulty discussing with patients, lack of confidence in DARE) and patient factors (perceived discomfort of DARE for patients, low anal cancer risk awareness). Physicians were willing to consider the idea of patient self-examination and partner-examination although concerns were raised regarding its reliability and issues surrounding partner dynamics. CONCLUSIONS: HIV physicians remain ambivalent regarding the most effective means to screen for anal cancer. More research is needed to address the physicians’ concerns before anal cancer screening can be implemented into routine HIV care.