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A 39-year-old HIV-infected man who has sex with men presents for routine care. He has been on tenofovir/FTC/efavirenz (Atripla) since his HIV diagnosis 2 years ago, when he had his first HIV test and was subsequently found to have a CD4 count of 140 cells/mm3. He tolerates this antiretroviral regimen well and maintains perfect adherence. At present, his CD4 count is 490 cells/mm3, his viral load is undetectable, and he has no symptoms of HIV disease. A rectal exam is normal, but an anal Pap smear comes back showing “atypical squamous cells of undetermined significance.”
What would you tell this patient about the significance of the Pap smear result? Would you repeat the test? If so, would you add human papillomavirus (HPV) testing, or do you do that for all anal Pap smears anyway? Is further evaluation (e.g., high-resolution anoscopy with biopsy) indicated? If so, would you refer the patient to someone else or do the examination yourself? If you refer, what is the specialty of the person doing the evaluation?
Two HIV specialists have now weighed in with their thoughts on management. View the discussion here.