Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Evaluation of the HIV-infected patient with anorectal symptoms

C Mel Wilcox, MD
Section Editor
John G Bartlett, MD
Deputy Editor
Jennifer Mitty, MD, MPH


Anorectal symptoms in the HIV-infected patient may reflect significant pathology and accurate diagnosis is essential to direct patient management.

The general approach to the evaluation and management of the HIV-infected patient with anorectal symptoms will be discussed here. The treatment of the various disease entities is discussed elsewhere (see appropriate topic reviews).


Anorectal disorders are associated with significant morbidity and have been commonly described among HIV-infected patients, particularly men who have sex with men (MSM) [1-5]. Common findings in this population include perirectal abscesses, anal fistulae, nonspecific ulcerations, infectious proctitis, anal warts, anal intraepithelial neoplasia, and anal cancer [6-9]. Less common noninfectious etiologies include ulcerative colitis or Crohn's disease.

Anorectal carcinomas are more common in MSM than in the general population, and the risk increases dramatically among those who are HIV-infected. In a population-based survey that examined cancer rates among AIDS patients from 1980 to 2006, the incidence of AIDS-related cancers (eg, Kaposi’s sarcoma) declined sharply while the incidence of some non-AIDS defining cancer, such as anal cancer, increased [10]. Furthermore, among persons with anal cancer, those with concomitant HIV infection were significantly younger at the time of diagnosis than those without HIV infection [11].

Risk factors for abnormal anal cytology in a study of 621 HIV-infected men and women included multiple human papillomavirus (HPV) types, immunosuppression (CD4 cell count <50 cells/mm3) and history of anal intercourse [12]. (See "HIV infection and malignancy: Management considerations".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Aug 20, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Hoentjen F, Rubin DT. Infectious proctitis: when to suspect it is not inflammatory bowel disease. Dig Dis Sci 2012; 57:269.
  2. Singhrao T, Higham E, French P. Lymphogranuloma venereum presenting as perianal ulceration: an emerging clinical presentation? Sex Transm Infect 2011; 87:123.
  3. Salit IE, Lytwyn A, Raboud J, et al. The role of cytology (Pap tests) and human papillomavirus testing in anal cancer screening. AIDS 2010; 24:1307.
  4. Hamadani A, Haigh PI, Liu IL, Abbas MA. Who is at risk for developing chronic anal fistula or recurrent anal sepsis after initial perianal abscess? Dis Colon Rectum 2009; 52:217.
  5. Barrett WL, Callahan TD, Orkin BA. Perianal manifestations of human immunodeficiency virus infection: experience with 260 patients. Dis Colon Rectum 1998; 41:606.
  6. Brewer DD, Golden MR, Handsfield HH. Unsafe sexual behavior and correlates of risk in a probability sample of men who have sex with men in the era of highly active antiretroviral therapy. Sex Transm Dis 2006; 33:250.
  7. Fox PA. Human papillomavirus and anal intraepithelial neoplasia. Curr Opin Infect Dis 2006; 19:62.
  8. Lee PK, Wilkins KB. Condyloma and other infections including human immunodeficiency virus. Surg Clin North Am 2010; 90:99.
  9. Machalek DA, Poynten M, Jin F, et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis. Lancet Oncol 2012; 13:487.
  10. Simard EP, Pfeiffer RM, Engels EA. Cumulative incidence of cancer among individuals with acquired immunodeficiency syndrome in the United States. Cancer 2011; 117:1089.
  11. Shiels MS, Pfeiffer RM, Engels EA. Age at cancer diagnosis among persons with AIDS in the United States. Ann Intern Med 2010; 153:452.
  12. Conley L, Bush T, Darragh TM, et al. Factors associated with prevalent abnormal anal cytology in a large cohort of HIV-infected adults in the United States. J Infect Dis 2010; 202:1567.
  13. Nahas CS, Lin O, Weiser MR, et al. Prevalence of perianal intraepithelial neoplasia in HIV-infected patients referred for high-resolution anoscopy. Dis Colon Rectum 2006; 49:1581.
  14. Cranston RD, Hart SD, Gornbein JA, et al. The prevalence, and predictive value, of abnormal anal cytology to diagnose anal dysplasia in a population of HIV-positive men who have sex with men. Int J STD AIDS 2007; 18:77.
  15. Wilkin T, Lee JY, Lensing SY, et al. Safety and immunogenicity of the quadrivalent human papillomavirus vaccine in HIV-1-infected men. J Infect Dis 2010; 202:1246.
  16. Mayer KH. Sexually transmitted diseases in men who have sex with men. Clin Infect Dis 2011; 53 Suppl 3:S79.
  17. Mayer KH, Bush T, Henry K, et al. Ongoing sexually transmitted disease acquisition and risk-taking behavior among US HIV-infected patients in primary care: implications for prevention interventions. Sex Transm Dis 2012; 39:1.
  18. Bolan GA, Sparling PF, Wasserheit JN. The emerging threat of untreatable gonococcal infection. N Engl J Med 2012; 366:485.
  19. McMillan A, Young H. Clinical correlates of rectal gonococcal and chlamydial infections. Int J STD AIDS 2006; 17:387.
  20. Nieuwenhuis RF, Ossewaarde JM, Götz HM, et al. Resurgence of lymphogranuloma venereum in Western Europe: an outbreak of Chlamydia trachomatis serovar l2 proctitis in The Netherlands among men who have sex with men. Clin Infect Dis 2004; 39:996.
  21. Ganesan A, Fieberg A, Agan BK, et al. Results of a 25-year longitudinal analysis of the serologic incidence of syphilis in a cohort of HIV-infected patients with unrestricted access to care. Sex Transm Dis 2012; 39:440.
  22. Boesecke C, Rockstroh JK. Acute hepatitis C in patients with HIV. Semin Liver Dis 2012; 32:130.
  23. European AIDS Treatment Network (NEAT) Acute Hepatitis C Infection Consensus Panel. Acute hepatitis C in HIV-infected individuals: recommendations from the European AIDS Treatment Network (NEAT) consensus conference. AIDS 2011; 25:399.
  24. Vogel M, Page E, Boesecke C, et al. Liver fibrosis progression after acute hepatitis C virus infection in HIV-positive individuals. Clin Infect Dis 2012; 54:556.
  25. Hoover KW, Butler M, Workowski K, et al. STD screening of HIV-infected MSM in HIV clinics. Sex Transm Dis 2010; 37:771.
  26. Klein EJ, Fisher LS, Chow AW, Guze LB. Anorectal gonococcal infection. Ann Intern Med 1977; 86:340.
  27. Singh R, Nime F, Mittelman A. Malignant epithelial tumors of the anal canal. Cancer 1981; 48:411.
  28. Schneider TC, Schulte WJ. Management of carcinoma of anal canal. Surgery 1981; 90:729.
  29. Schraut WH, Wang CH, Dawson PJ, Block GE. Depth of invasion, location, and size of cancer of the anus dictate operative treatment. Cancer 1983; 51:1291.
  30. White JA. Manifestations and management of lymphogranuloma venereum. Curr Opin Infect Dis 2009; 22:57.