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2000;285: 1736; Lancet 1998;351:1833). The rate increases with CD4 counts <500/mm3 (AIDS 1998;12:495).
- Method: No preparation is required. Use a Dacron (not cotton) swab to obtain the specimen before rectal exam, (i.e. before lubrication is introduced). The patient should not have had an enema or rectal sex in the prior 24 hours. The swab is moistened with saline or nonsterile water, the anus is spread so the aroderm points out, the swab is inserted into the anal canal; it must be inserted 2 cm from the anal verge. It is then moved in and out without withdrawl while rotating the swab with mild pressure to the anal well. The swab is immersed in methanol-based solution, agitated and submitted to the lab.
- Sensitivity and specificity: Sensitivity is high (95%) for detecting anal dysplasia but specificity is low (50%) for predicting biopsy results (Int J STD AIDS 2007; 18:77; CID 2006; 43:223). These figures are similar to those for cervical PAP smears. A review of 8 series indicated the sensitivity of 69%-93% and specificity of 32%- 59% for anal Pap smears (CID 2006;43:223).
- High resolution anoscopy (HRA): Patients with cytology results showing ASC-US, LSIL or HSIL should be referred for HRA which is comparable to cervical colposcopy. The American Society for Colposcopy and Cervical Pathology offers an annual workshop on HRA ( www.asccp.org/meetings.shtml).
INDICATIONS : are controversial and there is no consensus. Some authorities recommend anal Pap smears in all patients with histories of receptive anal intercourse at three year intervals, which is comparable to recommendations for cervical Pap smears (Am J Med 2000;108: 634). Others are more selective suggesting testing MSM and those with a history of anogenital carcinoma and women with histology showing abnormal cervical or vulvar histology (J Clin Oncol 2006;24: 4516).
TREATMENT : Abnormal anal Paps should lead to referral for high-resolution anoscopy and biopsy (CID 2004;38:1490). HAART is also important due to its profound impact on survival (Dis Colon Rectum 2004;47:1305).
EVALUATION : A meta-analysis of 21 published studies from 1996 to 2005 (CID 2006;43:223) concluded anal paps smears are of "modest accuracy" that is similar cervical Pap smears. Limitations are: 1) There are no randomized trials; 2) Few analyses evaluated treatment and 3) The natural history is poorly defined.
Hepatitis A Serology: HAV serology (total anti-HAV antibody) is performed to identify candidates for the HAV vaccine, which is indicated for susceptible persons with chronic HCV
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