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Vaccines

Administration of dose #1 of 9-valent HPV vaccination will be given at baseline visit, dose #2 at month 2, and dose #3 at month 6.

Administration of dose #1 of 9-valent HPV vaccination will be given at month 12, dose #2 at month 14, and dose #3 at month 18.

Gardasil-9 is a novel, 9-valent HPV recombinant vaccine, which expands the coverage of oncogenic HPV types, with the addition of HPV types 31, 33, 45, 52, and 58 to the existing quadrivalent vaccine types. The addition of these five oncogenic types is estimated to improve cancer coverage to 90% (versus 70% for the quadrivalent vaccine) \[38\]. With its expanded coverage of oncogenic HPV types, its proven efficacy in primary prevention and its potential role in mitigating HGAIN recurrences.

9-valent HPV vaccination

Irving Salit, MD

Grecia Higuerey

Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) worldwide. Infection by certain high-risk oncogenic types of HPV (HR-HPV) is the major cause of several cancers in men, notably squamous cell carcinoma (SCC) of the anal canal. Rates of anal infection with these HR-HPV strains, and the resultant high-grade anal dysplasia and anal cancer are much higher in men who have sex with men (MSM) than in the general population. Co-infection with human immunodeficiency virus (HIV) further amplifies this burden, making the rates of anal SCC in HIV-positive MSM higher than the historic rates of cervical cancer prior to the adoption of routine cervical cytology screening. Despite these alarming statistics, there are no established protocols for optimal screening and treatment of anal HPV and cancer precursors, nor has there been any widespread rollout of organized screening programs anywhere in Canada. Further, not only does HPV directly cause significant disease in these men, but there is growing epidemiologic evidence that HPV infection may enhance sexual transmission of HIV. These significant knowledge gaps translate into fundamental deficiencies in care for HIV-positive MSM.

The HPV Screening and Vaccine Evaluation in MSM (HPV-SAVE) study team was funded by the Canadian Institutes of Health Research (CIHR) via its Boys' and Men's Health Team Grant Competition. It aims to recruit a large group of MSM from various Ontario and Vancouver clinics, in order to carry out a number of different studies. The HPV-SAVE team brings together community and internationally-recognized experts in HPV and HIV disease and mucosal immunology, to better define the optimal approaches for primary and secondary prevention and treatment of HPV-associated anal disease among HIV-positive MSM, and to explore biological mechanistic evidence regarding the potential role of HPV as a co-factor for HIV transmission. This will yield critical information which can lead to improvement in the health of MSM, and will provide a foundation on which to build large-scale screening and treatment trials on a national level. A key part of this research program involves an analysis of the potential role played by the HPV vaccine in the overall management of HIV-positive MSM.

Planned vaccine-related projects include:

* A mixed-methods analysis of the knowledge, attitudes, and acceptability of HPV vaccination amongst HIV-positive MSM, through quantitative (e.g. cross-sectional survey) and qualitative (e.g. in-depth interviews) means.
* A comprehensive assessment of the 9-valent HPV vaccine in HIV-positive MSM, including safety and immunogenicity, as well as its potential role in secondary prevention of high-grade anal dysplasia. This is the study on which the current proposal is based.

Advances in the treatment of HIV-infected individuals with the advent of the combination antiretroviral therapy (cART) era has led to dramatic reductions in mortality and morbidity. These dramatic strides in survival within HIV-positive populations have led to a focus on longer-term morbidities in these individuals, including malignancies. Indeed, an increase in a variety of malignancies in HIV-infected individuals has been noted in the cART era. Amongst these are cancers associated with HPV, responsible for the vast majority of cervical cancers (itself a well-established acquired immune deficiency syndrome (AIDS)-defining illness), and 40-90% of anal, vulvar, vaginal, penile, and oropharyngeal cancers. More specifically, a recent meta-analysis indicates that the overall prevalence of HPV in anal carcinoma is approximately 84%, with HPV type 16 being isolated in 73% of all cases, making it the most prevalent type implicated in anal carcinoma.

Though infrequent at a rate of one per 100 000, squamous cell anal carcinoma is on the rise in the general population. It occurs at significantly higher rates in HIV-positive men - particularly among MSM - with an estimated rate of 60 to 160 per 100 000. A recent study of thirteen North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) with over 34,000 HIV-infected patients, found that anal cancer rates were highest in HIV-infected MSM, with a rate of 131 per 100,000 person years. In fact, rates of anal cancer among HIV-infected MSM are comparable to rates of cervical cancer in women prior to the adoption of routine screening for cervical dysplasia. In addition to its etiologic association with HPV, anal cancer shares many similarities with cervical cancer. Both are squamous cell cancers occurring at the squamo-columnar junction, and both likely arise from histologically-similar, dysplastic precursor lesions. It is postulated that a critical step in anal cancer carcinogenesis is the establishment of persistent infection (conventionally defined as greater than six or twelve months) with oncogenic HPV in the anal canal. Though the majority of HPV infections are considered transient and will eventually clear even in HIV-positive individuals, HIV-positive individuals have higher rates of persistent infection, especially with oncogenic HPV types.

Of the greater than 170 HPV types, over 30 favour the anogenital area, and on the basis of epidemiologic and phylogenetic data, these have been classified by the International Agency for Research on Cancer (IARC).

The vast majority of anal cancers (as well as cervical cancers) are caused by two high-risk HPV types: HPV type 16 and HPV type 18, felt to be responsible for 66% and 5% of anal cancers, respectively. However, a recent study from France examining the distribution of HPV types in cases of anal cancer found even more dramatic results: HPV was found in 96.7% of all cases, with HPV-16 being the most prevalent type (75%), with other high risk types (HPV-18, -52, -33, and -51) found in 4% to 6% of cases. Further, HPV-16 and -18 - either alone or in combination - were found in over 78% of cases. HPV lesions caused by low-risk types include condylomata (or commonly known as 'genital warts'), of which 90% are caused by HPV types 6 and 11.

Prevention strategies for anal cancers have emerged that are analogous to strategies used in cervical cancer screening, that rely on a combination of cytology (Papanicolaou, or Pap smear) and high-resolution anoscopy (HRA; analogous to colposcopy), both of which screen for high-grade anal intraepithelial neoplasia (HGAIN; typically graded as anal intraepithelial neoplasia (AIN) AIN-2 or -3). Despite the clear evidence indicating the benefit of screening and treatment procedures in cervical cancer screening, no large rigorous studies have been performed to assess the performance of such strategies in anal cancer screening in either men or women.

In addition to the scant literature on the efficacy of screening programs for anal cancer and HPV in all men - but particularly those who are HIV-positive - there remains an even greater paucity of data on issues surrounding primary prevention of HPV. The HPV quadrivalent recombinant vaccine, or Gardasil®, protects against HPV types 6 and 11, which are the most common types implicated in condylomata acuminata (anogenital warts), as well as the most common oncogenic strains, types 16 and 18. The use of this vaccine has been shown to prevent persistent cervical HPV infection caused by vaccine types in women, as well as preventing nearly all high grade genital lesions in women - the latter of which are considered precursor lesions to invasive cancers. Additionally, a retrospective pooled analysis of two large efficacy trials of quadrivalent HPV vaccine has also demonstrated a treatment effect from HPV vaccine in preventing recurrences of previously treated high grade cervical disease.

Few studies have been done on the use of the quadrivalent HPV vaccine in men; there has only been one study examining the use of the HPV vaccine in HIV-positive men, and this study found the vaccine to be safe and immunogenic. Overall, these studies have shown promise, demonstrating a reduction in vaccine-type genital lesions in young men who were vaccinated versus those receiving placebo, evidence of protection against HGAIN in MSM, and a 50% reduction rate in HGAIN recurrence in MSM previously treated for dysplastic lesions. This latter study lays the foundation of the currently proposed study. However, the role of the HPV vaccine in secondary prevention of HGAIN has not been examined in a systematic, prospective way. Given the unacceptably high rates of HGAIN recurrence in those having undergone ablative therapy (from 62% to 91% within two years in HIV-positive MSM), exploring this potentially novel benefit of the HPV vaccine is certainly warranted and could potentially change the way clinicians address HPV-related disease in this high-risk group.

Until recently there existed no standard recommendation for the use of HPV vaccinations in males, regardless of HIV serostatus; however, these studies have prompted the Centres for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) to recommend that boys be routinely vaccinated for HPV beginning at age 11 or 12. Canada's National Advisory Committee on Immunizations (NACI) went further, recommending vaccination in all males between 9 and 26 years of age, as well as any MSM 9 years of age or older.

Gardasil-9 is a novel, 9-valent HPV recombinant vaccine, which expands the coverage of oncogenic HPV types, with the addition of HPV types 31, 33, 45, 52, and 58 to the existing quadrivalent vaccine types. The addition of these five oncogenic types is estimated to improve cancer coverage to 90% (versus 70% for the quadrivalent vaccine). With its expanded coverage of oncogenic HPV types, its proven efficacy in primary prevention and its potential role in mitigating HGAIN recurrences - all coupled with the disproportionate burden of HPV-related anal cancers borne by HIV-positive MSM - it is critical that its use be comprehensively assessed in this very high risk population

This will be a randomized, open-label multicentre clinical trial consisting of two arms (immediate versus delayed vaccination) assessing the efficacy, safety and immunogenicity of the 9-valent recombinant HPV vaccine in HIV-positive males 18 years of age and older. The delayed arm will receive Gardasil-9 12 months after the immediate arm. Similarly, appropriate follow-ups and testing in the delayed arm will occur 12 months after the immediate arm.

Participants for the proposed study will be recruited from Canadian centres in Toronto, and Vancouver through ongoing projects making up our HPV-SAVE team grant. Other study sites may be added as the study progresses.

History of any sexual activity with men, or both men and women, where sexual activity is defined as oral, vaginal, or anal intercourse.

HPV-SAVE_Merck_Sub-Study for Preventing Recurrence of HSIL

A Multicenter, Randomized Controlled Trial of the Efficacy, Safety and Immunogenicity of HPV Vaccination in Preventing Recurrence of HSIL in HIV-positive MSM

Secondary Prevention. "Successful treatment" refers to a biopsy-proven HGAIN lesion treated with ablative therapy electrocautery (EC) with repeat biopsy of the same lesion 2-3 months thereafter demonstrating no further evidence of HGAIN (meaning that the follow-up biopsy is either AIN-1 or normal).

Immunogenicity. or this measure, immunogenicity will be measured as the proportion of participants with GMT of antibody to each vaccine type above a pre-specified, validated cut-off, using a Luminex-based immunoassay \[40-42\]. Currently, these values for the HPV types present in the 9-valent vaccine are: HPV-6, 30 milli-Merck units/ml (mMU/mL); HPV-11, 16 mMU/mL; HPV-16, 20 mMU/mL; HPV-18, 24 mMU/mL; HPV-31, 10 mMU/mL; HPV-33, 8 mMU/mL; HPV-45, 8 mMU/mL; HPV-52, 8 mMU/mL; and HPV-58, 8 mMU/mL .

Merck Sharp & Dohme LLC

University Health Network, Toronto

Immunodeficiency Clinic, Toronto General Hospital

Communicable Diseases

Papillomavirus Infections

Sexually Transmitted Diseases

Sexually Transmitted Diseases, Viral

DNA Virus Infections

Tumor Virus Infections

Genital Diseases

Urogenital Diseases

Oculocerebral Syndrome With Hypopigmentation

Eric Chow, PhD

Eric PF Chow, PhD

Anal cancer is overrepresented among gay, bisexual and other men who have sex with men (MSM), particularly those living with HIV. Australia was the first country to introduce a publicly funded national HPV vaccination program in 2007. This program was expanded to include schoolboys aged 12-13 years in 2013; with a 2-year catch-up for boys aged up to 15 years. In 2018, the 9-valent vaccine (covering genotypes 6/11/16/18/31/33/45/52/58) replaced the 4-valent vaccine in the national program.

The goal of the HYPER3 study is to determine the prevalence of anal, genital and oral HPV among 200 young gay and bisexual men aged 16-20 years who were eligible for the school-based 9-valent vaccination.

Participants will be required to complete a questionnaire and provide samples for HPV testing. No follow-up visits will be required.

1. Self-collected oral rinse sample for HPV testing
2. Self-collected penile swab for HPV testing
3. Clinician-collected anal swab for HPV testing

Human Papillomavirus in Young People Epidemiological Research 3

A Cross-sectional Study to Evaluate the Prevalence of HPV in Gay and Bisexual Men Aged 16-20 Years in Australia

The oral, penile and anal prevalence of quadrivalent vaccine types (6, 11, 16 and 18)

The oral, penile and anal prevalence of nonavalent vaccine types (6, 11, 16, 18, 31,33, 45, 52 and 58)

The oral, penile and anal prevalence of type-specific HPV types

The Alfred

University of Melbourne

Monash University

Associate Professor

Carcinoma

Carcinoma, Squamous Cell

HIV-infected male patients who refer to conducting sexual risk practices that enable HPV transmission

HIV-infected male patients who neglect conducting sexual risk practices that enable HPV transmission

HIV-infected female patients disregarding sexual risk practices

digital-anorectal exam, liquid-based cytology, human papillomavirus testing, high-resolution anoscopy

Screening for anal squamous intraepithelial lesions

Pompeyo Viciana, MD, PhD

Karin Neukam, PharmD, PhD

César Sotomayor de la Piedra

There is increasing awareness of augmenting risk of anal cancer in people living with HIV, especially among men who have sex with men (MSM). High resolution anoscopy (HRA) represents the gold standard to detect pre-cancerous anal high-grade squamous intraepithelial lesions (HSIL), however, the procedure is time-consuming, costly and, most importantly, the learning curve is very flat. This yields a poor implementation of anal screening and, likely, to an excess of otherwise preventable anal cancer. Other screening methods include digital ano-rectal examination, anal-rectal cytology and human papillomavirus (HPV) genotyping, since infection with high-risk HPV genotypes has been identified as the main reason for the development of HSIL. To date, there is no consensus in screening strategies. Furthermore, it remains unclear whether, in whom and to which extend the currently available topic and invasive treatment options for HSIL should be applied, given that the natural history of the development of anal cancer remains poorly understood. The present cohort study aims to provide real-life data on the screening, management and follow-up of HIV-infected MSM is warranted for a better understanding of anal cancer in this setting.

The development of anal precancerous squamous intraepithelial lesions (SIL) and cancer of the anus is mainly caused by infection with high-risk human papillomavirus genotypes (HR-HPV). There is increasing awareness of marked (40 to 130-fold) risk of anal cancer in people living with HIV, especially among men who have sex with men (MSM). With the changing scenario of comorbidities in the HIV-infected population, given the success of modern antiretroviral therapy, anal cancer has emerged as a leading neoplasia across different cohorts in Western countries. In 2014, almost 30000 people were newly diagnosed with HIV in Europe, the majority of cases (77%) being men. This was largely driven by HIV transmission between MSM, which accounted for 42% of all HIV diagnoses. Hence, the incidence of anal cancer is likely to increase in the years to come.

The number of experts who support the necessity of implementing wide programs of anal cancer screening in at-risk populations is rapidly growing. Indeed, both the European Guidelines for treatment of HIV-infected adults and the Guidelines of the Spanish AIDS Society (GESIDA) currently recommend the screening of anal cancer in HIV-infected subjects at risk. It is likely that in years to come, a general recommendation to screen for anal cancer in patients with different conditions associated with immunosuppression is established, as experienced in other populations. In this context, since HIV-negative MSM and women with a history of anogenital dysplasia, as well as transplant patients, exhibit excess risk of anal cancer, these populations have been typically screened in center with ongoing anal cancer screening programs.

Digital ano-rectal examination (DARE) is mainly accepted as the first screening procedure for anal high-risk SIL (HSIL), followed by anal-rectal cytology. Both represent simple methods, however, cytology shows an alarmingly low negative predictive value and furthermore, in case of an abnormal cytology, the patient is referred to high resolution anoscopy (HRA) for biopsy of acetowhite lugol-negative lesions in the anal epithelium, suggestive of HSIL. HRA performance is similar to cervical colposcopy, but unfortunately, the training process is by far longer, hampering its implementation and availability to highly-specialized centers with large cohorts of people living with HIV under care.

Although histological HSIL was identified as precursor of anal cancer, it remains unclear if, which and in whom treatment is indicated, since not all patients progress, a considerable proportion even regresses spontaneously and recurrence rates are high. Treatments currently available include topical imiquimod or 5-fluorouracil, as well as surgical treatment. Due to the lack of data, no consensus of HSIL management has been reached.

Taken together what was mentioned above, real-life data on the screening, management and follow-up of HIV-infected MSM is warranted for a better understanding of anal cancer in this setting.

Seville Cohort of People Living With HIV at Risk for Anal Cancer

A Study to Screen for Anal Precancerous Squamous Intraepithelial Lesions and to Prevent Anal Cancer in a Real-life Setting of People Living With HIV at Different Risk: the Seville HIV Anal Cohort

The proportion of patients with cancer of the anal squamous intraepithelial cells stage 0, defined as anal high-risk squamous intraepithelial lesions (HSIL) according to the Lower Anogenital Squamous Terminology.

Incidence rates per person-years of cancer of the anal squamous intraepithelial cells stage 1-4 observed over time as defined by the National Cancer Institute of the National Institutes of Health, US Department of Health and Human Services (www.cancer.gov).

Instituto de Biomedicina de Sevilla

Hospitales Universitarios Virgen del Rocío

PharmD, PhD

Ablative therapy involving electrocautery (EC) will occur for participants with AIN-2 and AIN-3. The Hyfrecator ® 2000 Electrosurgical System will be used for EC therapy.

The control arm includes active surveillance with observation alone; no treatment in AIN-2 and -3.

Lesion is ablated by the The Hyfrecator ® 2000 Electrosurgical System. During electrocautery (EC) with The Hyfrecator, a gentle brushing technique occurs and the tissue is removed with forceps.

The Hyfrecator ® 2000 Electrosurgical System

No treatment to AIN-2 or AIN-3, only active surveillance.

Observation Alone

Human papillomavirus (HPV) is the most common sexually transmitted infection worldwide. Infection by certain high-risk oncogenic types of HPV (HR-HPV) is the major cause of several cancers in men, notably squamous cell carcinoma (SCC) of the anal canal. Rates of anal infection with these HR-HPV strains and the resultant high-grade anal dysplasia and anal cancer are much higher in men who have sex with men (MSM) than in the general population. Co-infection with human immunodeficiency virus (HIV) further amplifies this burden, making the rates of anal SCC in HIV-positive MSM higher than the historic rates of cervical cancer prior to the adoption of routine cervical cytology screening. Despite these alarming statistics, there are no established protocols for optimal screening and treatment of anal HPV and cancer precursors, nor has there been any widespread rollout of organized screening programs anywhere in Canada. Further, not only does HPV directly cause significant disease in these men, but there is growing epidemiologic evidence that HPV infection may enhance sexual transmission of HIV. These significant knowledge gaps translate into fundamental deficiencies in care for HIV-positive MSM.

The HPV Screening and Vaccine Evaluation in MSM (HPV-SAVE) study team will recruit a large group of MSM from various Ontario and Vancouver clinics, in order to carry out a number of different studies. The HPV-SAVE team brings together community and internationally-recognized experts in HPV and HIV disease and mucosal immunology, to better define the optimal approaches for primary and secondary prevention and treatment of HPV-associated anal disease among HIV-positive MSM, and to explore biological mechanistic evidence regarding the potential role of HPV as a co-factor for HIV transmission. This will yield critical information which can lead to improvement in the health of MSM, and will provide a foundation on which to build further, large-scale screening and treatment trials on a national level. The primary aim of the current study is to systematically compare ablative therapy versus intensive observation alone (also known as 'watchful waiting') in outcomes relating to high-grade anal dysplasia.

Since the 1990s, combination antiretroviral therapy (cART) has markedly reduced HIV-related opportunistic infections and mortality \[1\], and increased the life expectancy of people living with HIV \[2\]. While acquired immune deficiency syndrome (AIDS)-defining malignancies have declined \[3,4\], non-AIDS defining malignancies continue to occur at higher rates in HIV-infected persons than in the general population \[4\]. Amongst these are cancers associated with HPV which is responsible for the vast majority of cervical cancers (itself a well-established AIDS-defining illness), and an estimated 90% of SCC of the anal canal \[5\]. cART not only fails to protect against anal pre-cancers and cancers \[4,6,7\], but the incidence of anal SCC is increasing in the cART era \[6,8\]. Because of this increasing burden of disease, there is an urgent need to find effective ways of preventing anal SCC in those living with HIV. This includes screening for anal cancer precursors and ablative treatment of these lesions.

Though it is infrequent at a rate of 1 per 100 000, anal SCC is on the rise in the general population \[9\]. It occurs at significantly higher rates in HIV-positive men - particularly among men who have sex with men (MSM) - with an estimated rate of 60 to 160 per 100 000 \[4\], and no evidence of slowing in the era of increased cART use \[10\] (See Figure 1). In fact, rates of anal cancer among HIV-infected MSM are comparable to rates of cervical cancer in women prior to the adoption of routine screening for cervical dysplasia \[11\]. According to data from the Public Health Agency of Canada, rates of cervical cancer in 1972 were 18 per 100 000, dropping to just under 8 per 100 000 in 2004 \[12\]. In addition to its etiologic association with HPV, anal cancer shares many similarities with cervical cancer. Both are squamous cell cancers occurring at the squamocolumnar junction \[13,14\] and both likely arise from histologically-similar dysplastic precursor lesions \[15,16\]. It is postulated that a critical step in anal cancer carcinogenesis is the establishment of persistent infection with oncogenic HPV in the anal canal \[16\]. Though the majority of HPV infections are considered transient and will eventually clear even in HIV-positive individuals \[17\], HIV-positive individuals have higher rates of persistent infection, especially with oncogenic HPV types \[18\].

Of the greater than 170 HPV types, over 50 favour the anogenital area and, on the basis of epidemiologic and phylogenetic data, these have been classified by the International Agency for Research on Cancer \[19\]. The vast majority of anal cancers (as well as cervical cancers) are caused by two high-risk HPV types: HPV type 16 and HPV type 18 which are responsible for 66% and 5% of anal cancers, respectively \[20\]. HPV lesions caused by low-risk HPV (LR-HPV) types include condylomata (commonly known as 'genital warts'), of which 90% are caused by HPV types 6 and 11 \[21\]. Prevention strategies for anal cancers have emerged that are analogous to strategies used in cervical cancer screening, in that the aim is to identify precursor lesions which can then be removed before progression to cancer. Screening and detection rely on a combination of anal cytology (Papanicolaou, or Pap smear), anal HPV detection and high-resolution anoscopy (HRA) which is analogous to colposcopy). Visually-directed anal biopsy during HRA is considered the gold standard for detecting dysplastic lesions such as high-grade anal intraepithelial neoplasia (HGAIN; typically graded as AIN-2 or -3) \[16,22\]. Anal cytology is generally used as a screening test to determine whether HRA is needed; however, cytology is an imperfect predictor of intra-anal HGAIN. Despite the clear evidence indicating the benefit of screening and treatment procedures in cervical cancer screening, no large rigorous studies have been performed to assess such strategies in anal cancer prevention in men or women.

The HPV-SAVE Study Team: HPV Screening and Vaccine Evaluation in Men Who Have Sex With Men

A Randomized Controlled, Open-label Trial Examining the Efficacy, Safety, and Tolerability of Ablative Therapies for High-grade Anal Dysplasia Versus Observation Alone in HIV-positive Men Who Have Sex With Men (MSM)

Histologic resolution of high-grade AIN after treatment completion, with ablative therapies or surveillance alone. Resolution of high-grade AIN will be defined as histologic diagnosis of AIN-1 or normal at the post treatment HRA.

Resolution of high-grade AIN after treatment on a per-lesion basis. Histologic resolution of high-grade AIN after treatment completion, with ablative therapies or surveillance alone. Resolution of high-grade AIN will be defined as histologic diagnosis of AIN-1 or normal at the post treatment HRA.

Recurrence rates of high-grade AIN following ablative therapy on a per lesion basis.

Number of participants assessed on safety, tolerability and acceptability of the different intervention arms and the different treatments in the ablative therapies arms. Evaluation of adverse events and questionnaire-assessed acceptability by intervention arms and ablative treatment type.

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
HPV-SAVE_Merck_Sub-Study for Preventing Recurrence of HSIL	NCT03947775	Anal Intraepith... Anal Cancer Human Papilloma...	9-valent HPV va...	18 Years -	University Health Network, Toronto
Human Papillomavirus in Young People Epidemiological Research 3	NCT05587725	Human Papilloma... HPV HPV Infection Anal Cancer Cancer Men HPV 16 Infectio...		16 Years - 20 Years	Monash University
Seville Cohort of People Living With HIV at Risk for Anal Cancer	NCT03713229	Anal Squamous I...	Screening for a...	18 Years -	Hospitales Universitarios Virgen del Rocío
The HPV-SAVE Study Team: HPV Screening and Vaccine Evaluation in Men Who Have Sex With Men	NCT02503111	Anal Dysplasia Human Papilloma... Anal Cancer	The Hyfrecator ... Observation Alo...	18 Years -	University Health Network, Toronto
Seville Cohort of People Living With HIV at Risk for Anal Cancer	NCT03713229	Anal Squamous I...	Screening for a...	18 Years -	Hospitales Universitarios Virgen del Rocío

Spots Global Cancer Trial Database for men who have sex with men