People living with HIV have a 20- to 90-times higher risk for anal cancer than the general population, but unlike cervical or colorectal cancer, there is no routine program to screen for anal cancer or pre-cancerous changes. Recent research shows that treating early anal disease reduces the risk of progression to anal cancer by 57%. Existing HIV guidelines recommend screening for early anal cancers. New guidelines released in 2024 recommend screening for pre-cancerous lesions. It is time to explore implementation of anal screening for people living with HIV. Access to anal screening should be fair, no matter people’s gender identity, sexual orientation, race, or where they live.
About the study
We are conducting the ACCESS Study (Anal CanCer Equity in Screening Services) with the overall goal to gather evidence for implementation of equitable anal screening for people living with HIV in Ontario. (“Anal screening” refers to screening for anal pre-cancers as well as screening for early-stage anal cancer).
Our goals are:
- To assess individual, healthcare provider, organization, and Ontario health system needs for adoption of anal screening;
- To co-create, with healthcare providers and HIV communities, implementation strategies for anal screening that are considered feasible and acceptable to deliverers and recipients;
- To implement and evaluate strategies designed to promote equitable screening uptake.
Methods
We will gather evidence in three phases. First, we will carry out interviews and focus groups to learn the needs of people living with HIV, healthcare providers, and Ontario’s health system. Next, we will work with clinicians and people living with HIV. We will prepare toolkits to train clinicians in anal screening. We will co-design media to educate people living with HIV about anal screening and encourage screening participation. Finally, we will learn how well anal screening works by implementing and evaluating it.
Impact
Our project will provide the evidence on how to effectively make anal cancer screening part of routine HIV care, to prevent anal cancer and improve quality of life among people living with HIV. Our equity focus and co-design approach will allow teams to identify and prioritize barriers specific to equity-deserving groups.
Documentation of health system needs for implementation (e.g., changes to OHIP billing codes, continuing medical education to train screening deliverers, and facilitators of regional referral centres) can support a robust anal screening cascade that is equitable and cost effective. Documentation of existing clinic practices, needs, and preferences, with evaluation of early implementation efforts, can help deliverers achieve competence in screening and promote organizational change to monitor equity and reach with quality improvement initiatives, so that anal screening becomes part of routine HIV care. Documentation of recipients’ needs and preferences ensures that the enterprise of anal screening remains anchored in the experiences of people living with HIV so that, ultimately, anal cancer will be prevented and quality of life will be improved.
To our knowledge, comparable studies are not occurring elsewhere; our innovative approach may serve as a model in other provinces and international.
Acknowledgements: This project would not have been possible without the contributions and advocacy efforts of Joanne Lindsay and Ron Rosenes.
