Screening Will Always Be Essential. Providers and Staff Discuss the Implementation of Anal Cancer Screening for Persons Living With HIV in Mexico City

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PURPOSE Screening for and treating anal squamous intraepithelial lesions (ASIL) in persons living with HIV (PLWH) prevents anal cancer but has not been widely implemented, especially in low-and-middle income countries. METHODS We conducted semi-structured qualitative interviews with providers and staff affiliated with two clinics from the Mexico City HIV program to understand barriers and facilitators to the implementation of a permanent anal cancer screening program. A limited program for anal cancer was already in place at these clinics as part of an international research collaboration. Interviews in Spanish were conducted in person or by video conference, audio-recorded, transcribed and thematically analyzed using domains from the Consolidated Framework for Implementation Research. RESULTS Between October 2023 and January 2024, we conducted 17 interviews, of which 9 were with nurses or physicians who were part of the existing screening research program and 8 were with referring physicians or administrators. Interviewees agreed that establishing a permanent screening program was necessary given documented high rates of ASIL. The most significant barriers were related to resources required to sustain a program, especially infrastructure for collecting and processing pathology specimens. The clinics’ current participation in a research collaboration was recognized as a facilitator that could help overcome barriers related to procurement of anoscopes and training staff. Some interviewees believed that given resource limitations, screening would have to be scaled up in a stepwise process, requiring the creation of triage strategies to identify and prioritize high risk patients for screening. Barriers related to patient participation included lack of patient knowledge and, particularly among cis-women, stigmatization and logistical challenges to attending appointments. The clinics’ patient-centered culture and existing educational and clinical workflows promoting preventive health were facilitators that could help overcome patient-level barriers. CONCLUSION Staff believed that establishing a permanent anal cancer screening program was necessary and possible but acknowledged that it would require additional external resources. In the next phase of data collection, we will interview PLWH who receive care at the clinics.

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