Normalize symptom reporting by asking direct, stigma-reducing questions, such as:
“Have you noticed bleeding, lumps or discomfort around your anus?”
Supporting Anal Cancer Screening in Primary Care for People Living with HIV
People living with HIV are at significantly increased risk (20 to 90 times) for anal cancer, primarily due to immunosuppression and persistent human papillomavirus (HPV) infection. Despite this risk, routine anal cancer screening remains inconsistent across Canada due to a lack of clinical guidance and limited provider awareness.
This tool supports primary care providers in the early identification, screening and follow-up of anal cancer and precancer, specifically high-grade squamous epithelial lesions (HSIL) among people living with HIV. Developed through a knowledge translation process and informed by high-quality guidelines and implementation research, the tool promotes a proactive, evidence-based approach that integrates anal cancer screening into routine HIV care.
Why is screening needed?
People living with HIV, especially men who have sex with men (MSM), face a significantly higher risk of developing anal cancer compared to the general population. (Spindler et al., 2024; Chromy et al., 2025; Hirsch et al., 2025)
Early detection through screening can reduce the risk of progression of HSIL to squamous cell carcinoma (SCC) by about 57%. (Palefsky et al., 2022)
Who to screen New
Anal cancer screening is recommended for people living with HIV:
Starting at age ≥35 for men who have sex with men (MSM) and transgender women (TW).
Starting at age ≥45 for all others.
Note: While anal cancer screening is also recommended for other at-risk populations beyond people living with HIV, this tool is specifically focused on supporting screening within HIV primary care settings. As such, recommendations for broader populations are outside the scope of this resource.
(Stier et al., 2024)
Recognizing and responding to symptoms
Anal cancer screening is intended for asymptomatic individuals at elevated risk. However, when patients present symptoms, they require diagnostic evaluation, not routine screening.
Common symptoms to ask about include:
- Anal pain or itching.
- Bleeding, particularly during bowel movements.
- A sensation of fullness or a lump in the anal canal.
- Visible anal lesions.
What to do next
If a patient presents with any of these symptoms, primary care providers should:
- Take an anal history to support appropriate evaluation. This may include asking about: sexual history, history of warts, anal intraepithelial neoplasia, hemorrhoids, fissures, fistulas, or prior anal surgery. (Hillman et al., 2019)
- Perform a Digital Anal Rectal Exam (DARE).
- Note: The procedure for DARE is not currently standardized. (Hillman et al., 2019)
- Refer the patient to a colorectal specialist, for further assessment.
- Once other conditions have been ruled out, consider high-resolution anoscopy (HRA) or biopsy.
(Hillman et al., 2019, Hirsch et al., 2025; Stier et al., 2024, Chromy et al., 2025)
Note: High-risk patients with symptoms should bypass routine cytology and proceed directly to diagnostic assessment and possible referral. (Spindler et al., 2024; Chromy et al., 2025; Hirsch et al., 2025)
What to say: Education and engaging patients
Education improves screening uptake; knowledge is often limited with patients and is an important step that should not be overlooked (Wheldon et al., 2023). Stigma, embarrassment, and provider discomfort are top screening barriers (Sam et al., 2025). Affirming communication improves trust and participation (Stier et al., 2024)
Key messages and communication tips
- Use inclusive, non-judgmental language.
- Acknowledge stigma and cultural barriers.
- Be transparent about what the exam involves to reduce fear and uncertainty.
- Use plain-language explanations and visual aids where possible.
- Share the patient tool/handout.
Health equity lens
- Black Indigenous, and racialized people lving with HIV report lower screening rates. (Gillis JL, 2020, Hirsch et al., 2025)
- Address barriers such as stigma, distrust and access.
- Use gender-affirming and anti-racist care principles.
Talking points
- “Anal cancer is rare, but much more common in people living with HIV.”
- “This type of cancer is preventable and treatable when caught early.”
- “Screening is quick, safe and often part of routine care.”
- Use supporting evidence if you think it would helpful
- “People living with HIV are at significantly increased risk to develop anal cancer.”
- “Screening and HSIL treatment, which would remove the potential cancer cells, reduce anal cancer risk by 57%.” (Stier et al., 2024)
- Normalize screening:
- “This is like a Pap test, just in a different location.”
Preparing to screen
Ensure your clinic is properly setup/prepared for screening:
- Determine the availability of high-resolution anoscopy referrals.
- This helps determine whether you can do precancer screening + DARE or only DARE.
- Infrastructure and exam room readiness
- Ensure appropriate exam space: clean, private, with adjustable examination tables.
- Stock supplies: gloves, lubricant, Dacron swabs, cytology fixative solution patient gowns, cleaning materials.
- Ensure laboratory is accepting samples and include appropriate requisition.
- Confirm EMR templates or screening documentation forms are in place for data capture.
How to screen: Recommended practices
Annual screening is recommended for people living with HIV. (Hirsch et al., 2025; NIH, 2024) The primary objective is to identify any palpable abnormalities that require further evaluation. (Hilman et al, 2019)
Digital Anal Rectal Exam
Preparation
Before performing a Digital Anal Rectal Exam (DARE), clinicians should conduct a risk assessment that includes documenting symptoms, relevant behaviours, and medical history. While this assessment should be part of routine care, informed consent must always be obtained prior to proceeding. If anal cytology, HPV DNA testing, or other sexually transmitted infection tests are planned, these should be performed before the DARE.
How to perform a DARE
When performing the Digital Anal Rectal Exam (DARE), begin by examining the perianal region, then use a lubricated, gloved finger to gently insert into the anal canal. Palpate the full 360° circumference, carefully assessing for any lumps, bumps, or areas of tenderness. Lesions can be very small, sometimes as tiny as a pinhead, so even subtle findings on palpation should be examined closely.
The following steps outline the procedure when the patient is positioned in the left lateral position:
The following steps outline the procedure when the patient is positioned in the left lateral position:
- Explain the procedure and ensure privacy and consent.
- Use lubricant generously (a topical anesthetic can be used if HRA follows).
- Gently part the buttocks with your non-examining hand to expose the anus.
- Apply lubricant to the anal verge using a gloved finger.
- Gently press on the sphincter to allow gradual relaxation before insertion.
6. Once relaxed, insert the lubricated index finger until you reach the free rectal space (above the anorectal ring, usually around the second finger joint).
Choose one of the following techniques:
A. Longitudinal Sweeps
7. Start in the proximal rectum and apply gentle lateral pressure.
8. Withdraw slowly while palpating distally toward the sphincter.
9. Reinsert and rotate finger 30° counter-clockwise, overlapping each area to ensure full coverage.
10. Sweep circumferentially to examine the entire anorectal ring and canal.
11. Pay special attention to:
- Posterior space
- Anterior walls and prostate (in men) or cervix/uterus (in women)
B. Circumferential Sweeps
7. Sweep the finger circumferentially in the rectum, applying gentle pressure.
8. Pull back into the anal canal and repeat the circular sweep throughout the canal.
9. Be mindful of the anterior aspect, which is easily missed.
12. Ensure full 360° coverage of the anal canal and distal rectum.
13. Palpate the prostate (men) or cervix/pouch of Douglas (women) through anterior wall.
14. Use the pad of your finger to examine the lateral and distal anal canal in both directions.
15. Note any abnormalities, tenderness, nodules, or asymmetry.
16. Check the glove for blood or discharge.
17. Repeat the exam if unsure or if visualization was incomplete.
Note: A thorough DARE may take up to 1 minute. With practice, clinicians can complete it more efficiently while maintaining patient comfort.
For more information refer to the International Anal Neoplasia Society Guidelines for the Practice of Digital Anal Rectal Examination.
Anal Cytology (Pap test)
Anal cytology should be performed in combination with DARE where feasible, but always before DARE, as lubrication used during DARE can interfere with sample quality. This test should only be conducted when referral for high-resolution anoscopy (HRA) is available. No patient preparation is required. (Spindler et al., 2024)
To collect the sample, use a moistened nylon or polyester swab (tap water is sufficient) and insert it into the anal canal. Rotate the swab 360° while applying firm lateral pressure so that it bends slightly. Then, slowly withdraw the swab over 15 to 30 seconds, maintaining the circular motion throughout the withdrawal. (Anal Neoplasia Clinic, 2023)
What to do next: Referral and follow-up
Acknowledging that specialist wait-times can be lengthy for many patients, it is still important to do so as as promptly as possible. Timely specialist referral improves outcomes (Hirsch et al., 2025). Immediate evaluation is needed for symptomatic patients or those with abnormal results. (Spindler et al., 2024)
Referral guidelines
Refer abnormal cytology or hrHPV results, or any concerning DARE findings, to specialists trained in HRA.
List of clinics that do HRA (TBD)
If HRA is unavailable, consider anoscopy and biopsy by experienced clinicians. While specialists typically manage treatment and follow-up for patients diagnosed with high-grade squamous intraepithelial lesions (HSIL), it’s important for primary care providers to understand what this process may involve supporting ongoing care and patient education. Further surveillance and follow-up are determined by the HRA specialist based on the patient’s findings.
(Hirsch et al., 2025; Stier et al., 2024)
References
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[1]
Hirsch et al. (2025). NYSDOH AIDS Institute Guidelines.
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[2]
Chromy et al. (2025). German-Austrian Guideline on Screening for Anal Carcinoma in PLHIV.
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[3]
Gillis JL, Grennan T, Grewal R, et al. Racial Disparities in Anal Cancer Screening Among Men Living With HIV: Findings From a Clinical Cohort Study. J Acquir Immune Defic Syndr. 2020;84(3):295-303.
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[4]
Spindler et al. (2024). French Recommendations for Clinical Practice.
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[5]
Stier et al. (2024). International Anal Neoplasia Society Consensus Guidelines.
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[6]
NIH, CDC, HIVMA, IDSA. (2024). Guidelines for the Prevention and Treatment of Opportunistic Infections.
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[7]
Sam et al. (2025). Systematic Review of Screening Barriers Among MSM
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[8]
Palefsky et al. (2022). Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer
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[9]
Hillman, Richard John MD; Berry-Lawhorn, J. Michael MD; Ong, Jason J. PhD; Cuming, Tamzin MD; Nathan, Mayura MD; Goldstone, Stephen MD; Richel, Olivier MD, PhD; Barrosso, Luis F. MD; Darragh, Teresa M. MD; Law, Carmella MD; Bouchard, Céline MD; Stier, Elizabeth A. MD; Palefsky, Joel M. MD; Jay, Naomi PhD. International Anal Neoplasia Society Guidelines for the Practice of Digital Anal Rectal Examination. Journal of Lower Genital Tract Disease 23(2):p 138-146, April 2019.