A 53-year-old HIV-positive man presented to his family physician (FP) with a 7-month history of painful lesions around the anus. He stated that it hurt to go to the bathroom and that he had noticed blood on the toilet tissue after wiping. He was not currently sexually active but had many male sexual partners in his young adult years and regularly engaged in receptive anal intercourse. He’d had perianal warts on and off for a number of decades. These had been treated with liquid nitrogen and topical medicines with temporary success—and frequent recurrences.