High Rates of High-risk HPV Anal Infection and Abnormal Cytology in a Cohort of Transgender People Assigned Male at Birth

Background: Transgender people assigned male at birth (TG-AMAB) have higher rates of anal human papillomavirus (HPV) infection and anal cancer compared with cisgender populations. In a cohort of TG-AMAB in Washington DC, we determined the prevalence and epidemiological factors associated with anal high-risk HPV (HR-HPV) infection and cytological abnormalities.

Methods: In an urban academic-community clinic, we recruited adults identifying as a gender different than their sex assigned at birth. Participants provided blood samples, anal swabs for HR-HPV and cytology, and completed surveys on sexual behaviors and use of gender-affirming hormones. Logistic regression was used to identify predictors of HR-HPV and abnormal cytology.

Results: Of 97 TG, 80 were AMAB, of whom 66% were people with HIV (PWH); 73% tested positive for any anal HR-HPV, and 48% had abnormal cytology. Only 24% recalled HPV immunization. While TG-AMAB PWH had increased risk of HPV16 infection (37% vs 8%; P = .014), the prevalence rates of any HR-HPV (80% vs 62%; P = .097) and abnormal cytology (56% vs 32%; P = .085) were similarly elevated regardless of HIV status. Among TG-AMAB, estradiol use was not associated with increased odds of any HR-HPV or abnormal cytology (all P > .05); however, higher testosterone levels were associated with any HR-HPV (P = .014). Age ≥35 years was associated with abnormal cytology in TG-AMAB (59% vs 34%; P = .035).

Conclusions: TG-AMAB have a high prevalence of any HR-HPV and abnormal cytology, regardless of age, HIV status, or hormone use. Given high risk for anal cancer and low rates of HPV vaccination, there is a pressing need for primary and secondary anal cancer prevention strategies targeting this population.