Open Access Open Badges Research article

Regional and national guideline recommendations for digital ano-rectal examination as a means for anal cancer screening in HIV positive men who have sex with men: a systematic review

Jason J Ong1*, Marcus Chen23, Andrew E Grulich4 and Christopher K Fairley123

Author Affiliations

1 Melbourne School of Population and Global Health, University of Melbourne, 580 Swanston Street, Carlton, Victoria 3053, Australia

2 Melbourne Sexual Health Centre, 580 Swanston Street, Carlton, Victoria 3053, Australia

3 Central Clinical School, Monash University, Clayton Victoria 3168, Australia

4 Kirby Institute, University of New South Wales, Sydney NSW 2052, Australia

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BMC Cancer 2014, 14:557  doi:10.1186/1471-2407-14-557

Published: 1 August 2014



Although anal cancer is common in HIV positive men who have sex with men, few centres offer systematic screening. Regular digital ano-rectal examination (DARE) is a type of screening that has been recommended by some experts. How widely this forms part of HIV management guidelines is unclear.


The protocol was registered prospectively (CRD42013005188; webcite). We systematically reviewed 121 regional and national HIV guidelines and searched for guidelines from webcite, PubMed and Web of Science databases up to 5th August 2013 for recommendations of DARE as a means of anal cancer screening in HIV positive MSM. Guidelines were examined in detail if they were clinical guidelines, including both prevention and treatment protocols and were in English. Guidelines were excluded if they were restricted to limited areas (e.g. antiretroviral therapy only, children or pregnant women, strategies for prevention/testing). Information was extracted regarding recommendation of DARE as a screening method, the frequency of DARE recommended, target population for screening and the strength of evidence supporting this.


30 regional and national guidelines were included and examined in detail. Only 2 recommended DARE. The ‘European AIDS Clinical Society Guidelines’ recommends DARE every 1–3 years for HIV positive MSM whilst the ‘US Guideline for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents’ recommends an annual DARE for the HIV + population in general. None of these guidelines specify the age of commencing screening. In each case, the highest level of evidence supporting these two recommendations was expert opinion.


Few HIV guidelines discuss or recommend DARE as a means of anal cancer screening. Studies of the efficacy, acceptability and cost-effectiveness of DARE are needed to assess its role in anal cancer screening.

Anal cancer screening; Systematic review; Guidelines; Digital ano-rectal examination; HIV positive; Men who have sex with men