EP480 - Access to High Resolution Anoscopy Among Women and Transgender People: Systematic Review and Meta-Analysis Revealing a Major Gap in Knowledge

Purpose/Background: The ANCHOR trial demonstrated that identification and treatment of high-grade squamous intraepithelial lesions (HSIL) utilizing High Resolution Anoscopy (HRA) in people living with HIV decreases the incidence of anal cancer. Barriers to accessing HRA are largely described in studies focusing on cisgender men who have sex with men. However, women were recently designated in a National Cancer Institute study as having the largest incremental rise in anal cancer incidence rates, 2.9% vs 1.6% for men. We performed a systematic literature review to identify completion rates and barriers in anal cancer screening for women and transgender people with HIV.

Methods/Interventions: Approval for this systematic review was obtained through Prospero [CRD420251091215]. A systematic literature search was performed utilizing MedLine and Embase. Four independent reviewers screened the studies and performed data analysis, with conflict resolution by a fifth reviewer. Inclusion criteria included women and transgender people living with HIV/AIDS, age >18 years old and anal cancer screening, more specifically high-resolution anoscopy. Reviews, case reports/series, expert opinions, consensus guidelines, and abstracts only were excluded. All information is presented according to the Preferred Reporting Item for Systematic Reviews and Meta-Analysis (PRISMA). The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) criteria were used to assess the certainty of evidence. Statistical R© software was used for data analyses. A random-intercept logistic regression model was utilized. A maximum-likelihood estimator for τ2 was used to assess for heterogeneity. A random effects confidence interval based upon t-distribution (df =2) was applied to account for uncertainty in the estimation of τ2.

Results/Outcomes: 887 articles were screened and 21 were identified for analysis. Data extraction identified three papers (n=276) that focused specifically on high-resolution anoscopy completion rates in women and transgender people living with HIV/AIDS. The pooled HRA completion rate was 51% [95% CI, 11%-89%]. The studies had significantly different designs and endpoints. Eighty-eight percent of the total variability was due to true differences between the studies, suggestive of heterogeneity between studies. A meta-analysis was not completed due to study heterogeneity. Qualitative barriers identified in anal cancer screening in women and transgender people living with HIV/AIDS were grouped into provider-related, patient-specific, and systems-based factors (Table 2).

Conclusion/Discussion: There is scant quantitative research on barriers to HRA for early detection of HSIL and anal cancer for women and transgender people living with HIV. Many barriers have been qualitatively described. Further studies would facilitate quality improvement projects to increase access to HRA for women and transgender people living with HIV.

PRISMA flow diagram
Study selection diagram detailing the studies included in systematic review
Qualitative Barriers to Anal Cancer Screening
Barriers described by papers included in systematic review