High-resolution anoscopy in HIV-infected men: Assessment of the learning curve and factors that improve the performance

OBJECTIVE: To determine the required learning time for high-resolution anoscopy (HRA)-guided biopsy to detect histological high-risk squamous intraepithelial lesions (hHSIL) and to identify factors that impact on the training process. METHODS: All HIV-infected, screening-naïve men-who-have-sex-with-men who underwent HRA conducted by one single observer from 2010 to 2017 in a Spanish HIV-outpatient clinic were analysed. RESULTS: Eighty-five (14.7%) of the 581 patients included presented hHSIL. The factors associated with the capacity to detect hHSIL [adjusted odds ratio (aOR), 95% confidence interval (95%CI)] were the presence of cytological HSIL (3.04, 1.78–5.21; p < 0.001), infection with high-risk human papilloma virus (HR-HPV) (2.89, 1.38–6.05; p = 0.005), the number of biopsies taken/HRA (aOR: 1.28, 1.07–1.52; p = 0.006) and tobacco smoking (1.75; 1.12–2.73; p = 0.014). Two events independently augmented the detection rate of hHSIL: one single experienced pathologist interpreted biopsies after 409 HRA (2.80, 1.74–4.48; p = 0.035) and the anoscopist underwent an additional training after 536 HRA (2.57, 1.07–6.16; p = 0.035). A learning process could be observed throughout the whole study with stable HR-HPV prevalence. CONCLUSION: The data support the growing evidence that the proposed training volume of 50–200 performances is underestimated. Extensive training of both anoscopist and pathologist is warranted and the development of tools to support the diagnostic performance may be considered.