Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)


Nursing Science

Research Advisor

Wendy M. Likes, Ph.D., D.N.Sc


Marye Bernard, D.N.P. Satish Kedia, Ph.D. Cynthia K. Russell, Ph.D. Elizabeth A. Tolley, Ph.D.


anal cancer, barriers, facilitators, HIV, PLWHA, sexual health


Background: The incidence of anal cancer is only 1-2 per 100,000 people in the general population, but in people living with HIV and AIDS (PLWHA), the incidence is far greater by about 80 times. This is a striking disproportion, and it is vital for the healthcare provider and healthcare system to become more attentive to the risk of anal cancer in high-risk populations such as PLWHA. There are a number of modifiable risk factors for anal cancer in PLWHA such as smoking, non-adherence to antiretroviral therapy (ART), and risky sexual behaviors. The HIV primary care provider (HIV PCP) plays a major role in working with patients to address those risk factors through anal cancer risk factor management (ACRFM). The issue is that anal cancer and anal health are rarely addressed in the HIV primary care setting, and with anal cancer being on the rise in high-risk populations, the lack of risk factor management could become a major healthcare issue. This study sought to understand HIV PCPs’ current practices of screening for anal cancer risk factors and intervening to manage those risk factors. It also sought to understand their knowledge, confidence, and attitudes towards managing each risk factor in order to determine if there is a relationship between their knowledge, confidence, and attitude and their practices. Because anal health, a component of sexual health, is so poorly discussed in primary care, this study also sought to understand the factors that HIV PCPs see as facilitating or impeding their approach to discussing anal health with their patients. The overall purpose of the study was to understand ACRFM practices and the barriers and facilitators of addressing anal health in the HIV primary care setting.

Methods: In this exploratory study, a descriptive correlational design was used to assess ACRFM quantitatively. The barriers and facilitators of discussing anal health in the HIV primary care setting were explored qualitatively. A 20-question ACRFM survey was developed and administered to HIV PCPs in MS, TN, and AR. Data were analyzed using descriptive statistics, confidence interval hypothesis testing for mean values, and Spearman’s correlation coefficients. HIV PCPs were then randomly selected from survey participants for individual interviews. Five interview questions were used to understand the barriers and facilitators of discussing anal health in the HIV primary care settings. Interview transcripts were analyzed for codes that would fall into two major categories: barriers and facilitators of discussing anal health.

Results: There were 20 HIV PCPs who participated in the quantitative portion of the study. HIV PCPs were less likely to practice towards managing risky sexual behaviors (2.57 ± 1.2) when compared to smoking and non-adherence to ART. Knowledge, confidence, and attitude (KCA) scores were statistically higher towards management of non-adherence to ART, but all KCA scores were high (≥ 4.0 on a scale of 5.0). There was a moderate relationship between the knowledge of managing risky sexual behaviors and practices towards managing risky sexual behaviors (r=. 56699, p=. 0091). There were 10 HIV PCPs randomly selected from the sample of survey participants, and 9 agreed to participate in brief one-on-one interviews. There were two major categories, barriers and facilitators of discussing anal health in the HIV primary care setting, and a total of ten codes. There were seven barrier codes: external issues, demand of other priorities, perception of patient embarrassment, lack of resources, provider embarrassment, lack of anal complaints, and gender discordance. There were 3 facilitator codes: awareness, advantageous circumstances, and the patient-provider relationship. Anal health was confirmed as a component of sexual health.

Conclusions: HIV PCPs were found to have high knowledge, confidence, and attitude scores towards managing all anal cancer risk factors. This finding indicated that other factors might have contributed to a lesser likelihood of managing risky sexual behaviors in the HIV primary care setting other than knowledge, confidence, and attitude. The lack of resources related to screening for risky sexual behaviors and intervening to reduce risky sexual behaviors was hypothesized as one reason to explain this finding. Barriers of addressing anal health such as lack of time, the demand of other issues, the lack of anal health complaints, personal embarrassment, and issues related to gender discordance were also identified as factors to explain this finding. An implication for future practice includes the development of resource guides specific to ACRFM. Another implication includes the implementation of preventative health visits for ACRFM in HIV primary care as an effort to reduce issues related to time constraints and competing demands. A nationwide improvement of sexual health and anal health education is also recommended in training programs for all healthcare professionals in order to reduce issues related to personal embarrassment.