Background:

Anal cancer risk is elevated among people with HIV (PWH), particularly in men who have sex with men with HIV. Estimating survival by HIV status and sex and identifying high-risk groups is critical for documenting prognostic differences between populations.

Methods:

We used data from linked HIV and cancer registries in the U.S. on anal cancer patients aged 20–79 diagnosed during 2001–2019. We assessed sex-specific adjusted hazard ratios (aHRs) of all-cause and anal cancer-specific mortality by HIV status using Cox proportional-hazard models, adjusting for year, age, race/ethnicity, histology, stage, region, and treatment. We identified predictors of mortality by HIV status. Models among PWH further adjusted for AIDS and HIV transmission group.

Findings:

Between 2001–2019, 43·6% (1161) of 2662 PWH with anal cancer died versus 35·4% (7722) of 21824 patients without HIV. HIV was associated with a 1·35-fold [95% confidence interval (95%CI)=1·24-1·47] increase in all-cause mortality among male patients, and a 2·47-fold (95%CI=2·10-2·90) increase among female patients. Among PWH with anal cancer, all-cause mortality was greater among non-Hispanic Black individuals (aHR=1·19, 95%CI=1·04-1·38), people with AIDS (aHR=1·36, 95%CI=1·10-1·68), people who inject drugs (PWID) (aHR=1·49, 95%CI=1·17-1·90), those with adenocarcinoma (aHR=2·74, 95%CI=1·82-4·13), and those without surgery treatment (aHR=1·34, 95%CI=1·18-1·53). HIV was associated with anal cancer-specific mortality among female patients only (aHR=1·52, 95%CI=1·18-1·97). Among PWH, anal cancer-specific mortality was greater among those with adenocarcinoma (aHR=3·29, 95%CI=1·89-5·72), those with no/unknown treatment compared to any treatment with either surgery, radiation, and/or chemotherapy (aHR=1·59, 95%CI=1·17-2·17), and among PWID (aHR=1·60, 95%CI=1·05-2·44).

Interpretation:

Among anal cancer patients, HIV was associated with all-cause mortality, with a much stronger association among female patients. Anal cancer-specific mortality was elevated among female patients with HIV. As anal cancer screening becomes more widespread, examining impacts of screening on survival by HIV status and sex is crucial.

Funding:

U.S. National Cancer Institute Intramural Research Program.