Richard Goldman lived with HIV for at least five years with minimal symptoms, continuing his work as a physician assistant. When he experienced rectal pain at age 40, his doctor initially attributed it to hemorrhoids. Months later, Goldman discovered the cause was anal cancer. At the time, in 1989, the link between anal cancer and human papillomavirus (HPV) was just beginning to be understood. It wasn’t until the mid- to late-1990s that researchers identified the heightened risk of HPV-related anal cancers in individuals with HIV.
Goldman’s doctors were uncertain how to approach treating anal cancer in someone with a compromised immune system, advising him to "get his affairs in order." He described the experience of undergoing chemotherapy and radiation without a robust immune system as frightening. Thirty-seven years later, Goldman feels fortunate to be alive, crediting the support of his friends for helping him through the ordeal.
Immune Suppression and HPV-Related Cancers
Current medical knowledge about HPV-related anal cancers is significantly more advanced than during Goldman’s diagnosis. HPV, a virus transmitted through intimate contact, is responsible for several types of cancer, including anal, cervical, head and neck, penile, vaginal, and vulvar cancers. While a healthy immune system typically manages HPV effectively, individuals with weakened immune systems, such as those with HIV or transplant recipients, face a substantially higher risk.
A recent study published in JAMA Network Open indicates that individuals with HIV are 4.5 times more likely to develop an HPV-driven cancer, and organ transplant recipients are more than twice as likely. The risk is particularly elevated for anal cancer among people with HIV, who are 59 times more likely to develop it compared to the general population, according to the study. They also have an increased risk for penile and vulvar cancers, and a higher likelihood of developing cervical cancer. While the study found no significant increase in head and neck cancers, data on vaginal cancers was not included.
In the United States, approximately 11,300 new cases of anal cancer are diagnosed annually, resulting in about 1,700 deaths. Although women constitute the majority of anal cancer diagnoses, men face a higher risk. The new study reveals that straight men with HIV are over six times more likely to develop anal cancer, while men who have sex with men have a five times higher risk. Mark Einstein, MD, chair of obstetrics and gynecology at Montefiore Einstein Medical Center, noted that the anal cancer risk for HIV-positive men who have sex with men now surpasses the risk of cervical cancer seen in women before the widespread adoption of Pap tests. The study also highlighted that individuals with poorly controlled HIV have an 8.6 times greater chance of developing an HPV-related cancer, while even those with well-managed HIV have a 3.9 times higher risk.
Preventing HPV-Caused Diseases
Despite rising anal cancer rates, particularly among older women, there are now more preventive measures available. Merck’s Gardasil HPV vaccine, approved by the FDA, protects against six types of cancer, including anal cancer, by targeting nine viral strains, including HPV 16, which is a primary cause of anal cancers.
Clinical trials have shown that vaccinating males who have sex with men before age 26 significantly reduced the risk of anal precancers by 75% compared to unvaccinated individuals. Real-world analyses suggest a 50% reduction in precancerous conditions. A study in JAMA Oncology this year found that vaccinated men had a 50% lower risk of HPV-related cancers, including head and neck, esophageal, anal, and penile cancers. Gardasil is recommended for individuals aged 9 to 26 and is available to those up to age 45 after a discussion with a healthcare provider. George Froehle, a physician assistant and HIV specialist, advocates for offering the HPV vaccine to all eligible patients, regardless of age. While it may take decades to observe the impact of HPV immunization on anal cancer rates due to the typical age of diagnosis being 65, current vaccination rates among U.S. teens are encouraging, with about 78% receiving at least one dose.
Screening for Anal Precancerous Conditions
Healthcare providers can also screen and treat individuals at high risk for anal HPV. A significant study in the New England Journal of Medicine in 2022 demonstrated that screening and treating anal precancers in people with HIV reduced the progression to cancer by 57%. Anal cancer screening is comparable to cervical cancer screening, involving HPV testing and an anal Pap test to examine cells for abnormalities. If abnormal cells are detected, a procedure called anoscopy is performed to examine the anal canal and collect tissue samples if necessary. Precancerous lesions can be removed before they become malignant.
Kyle Benda, DO, medical site director at Whitman-Walker Health, recommends anoscopy for anyone with HPV 16, even with normal Pap test results. He also supports self-testing options for anal HPV, which can increase patient willingness to be screened. In 2024, the International Anal Neoplasia Society published guidelines recommending screening for individuals at high risk for anal cancer. These guidelines suggest initiating screening at age 35 for HIV-positive transgender women and men who have sex with men, and at age 45 for other individuals with HIV. For those without HIV, screening is recommended at age 45 for transgender women and men who have sex with men. Individuals with a history of vulvar cancer or precancer should be screened within a year of diagnosis, and solid-organ transplant recipients should undergo screening within 10 years of their transplant.
Gaps in Care
Despite these advancements, a considerable number of individuals at high risk for anal cancer are not being screened. Patrick Eucalitto, MD, of Montefiore Einstein Medical Center, stated that only half of people with HIV have undergone an anal Pap test. Infectious disease specialist Eric Meyerowitz, MD, emphasized the critical need to raise awareness about the risks of HPV-related cancers associated with HIV infection and immunosuppression. While many clinics offer anal Pap tests, fewer provide anoscopy or high-resolution anoscopy, procedures requiring specialized training and often necessitating travel to larger cities.
Richard Goldman believes that increased public awareness of anal cancer risks and preventive measures is essential. While the heightened risk among people with HIV is generally known, education within the broader LGBTQ community remains inconsistent. The stigma surrounding anal cancer poses a significant barrier to awareness efforts. Goldman also points out that the risk is not exclusive to individuals engaging in anal sex. He stresses the importance of discussing anal health openly, as proactive measures can be taken. "Every community needs to work on knowing more about conditions that affect us all," Benda commented, advocating for non-judgmental conversations about HPV among healthcare providers.
"We are miracles"
Goldman shares his story to prevent others from experiencing similar hardships. He volunteers with the Anal Cancer Foundation as a support buddy for newly diagnosed individuals. Reflecting on his long-term survival with AIDS, Goldman describes himself and others in his support group as "dinosaurs." He acknowledges the physical toll but emphasizes the remarkable achievement of living beyond initial expectations, calling them "miracles" for having survived so long.