Are Cancer Risks Higher for People Living with HIV/AIDS

For many years, scientists have been exploring the relationship between HIV/AIDS and various cancers. This complex connection stems from how the virus weakens the immune system, leaving folks more vulnerable. While there has been evidence of higher prevalence of certain cancers amongst people living with HIV/AIDS (PLWHA), the actual mechanisms have thus far remained unclear.

Recently, a team from Hospital 12 de Octubre (H12O) and the National Cancer Research Centre (CNIO) in Madrid, Spain found that Hepatitis B and C viral infections can cause multiple myeloma and its pathological precursors, monoclonal gammopathies. Additionally, they found that early detection of viral hepatitis and the use of antiretrovirals resulted in better health outcomes in general – taking care of the hepatitis and the monoclonal gammopathies/multiple myeloma at the same time.

This groundbreaking discovery comes shortly after the data was made available from the HIV/AIDS Cancer Match Study, which links United States’ HIV surveillance and cancer registry data from 2000 to 2019. Haas et al. examined this data and created a population-based linkage study which garnered the largest cohort to date for estimating anal cancer among PLWHA in the United States, with a cohort of 3,444 anal cancers diagnosed in patients with HIV. Of these 3,444 cases, 2,678 occurred in patients with a prior AIDS diagnosis.

Additionally, several cancers have been identified as AIDS-defining illnesses. The presence of these conditions indicates that the patient has reached the advanced stage of HIV infection known as AIDS. These include invasive cervical cancer, Kaposi’s sarcoma, and some iterations of lymphoma (e.g. diffuse large B-cell lymphoma and Burkitt or Burkitt-like lymphoma). A 2021 meta-analysis of twenty-four studies found that women with HIV are six times more likely to have cervical cancer than their counterparts without HIV. This is likely due to the inability to clear human papillomavirus (HPV) infection, which can cause cervical cell changes if left untreated in some cases. According to Lymphoma Action, diffuse large B-cell lymphoma is around fifteen times more common in PLWHA, while PLWHA are around 30 times more likely to develop Burkitt lymphoma.

As is often the case when living with HIV/AIDS and co-occurring conditions, early detection, open and frequent communication with healthcare providers, and HIV/AIDS treatment regimen adherence can make a significant difference in the duration and intensity of these conditions, so patients should be encouraged to be vigilant self-advocates when it comes to their health and wellness, and, when needed, identify resources among caregivers and community who might be able to assist in care advocacy.

Eddie Hamilton (left), Bill Arnold (right)

CANN would like to recognize the fierce advocacy of our colleague, friend, and former board member, Edward “Eddie” Hamilton (pictured). Eddie served on CANN’s Board of Directors from 2014 to 2022 and was the Founder and Executive Director of the ADAP Educational Initiative, which assisted clients enrolled under the AIDS Drug Assistance Program (ADAP). In 2012, Eddie was honored as the ADAP Champion of the Year by ADAP Advocacy for fighting the Ohio Department of Health’s attempts to implement medical eligibility criteria to qualify for ADAP services. Eddie passed away on July 12, 2022, having had cancer twice. CANN continues to honor Eddie’s legacy as well as that of the late Bill Arnold (pictured right), who served as CANN’s founding President & CEO, by championing patient-centric action toward health equity and access.

Feds Launch National HIV/AIDS Strategy Implementation Plan

On August 26th, the White House Office of National AIDS Policy (ONAP) director, Harold Phillips, announced publication of the Federal Implementation Plan for the National HIV/AIDS Strategy. A “dear Colleague” letter was circulated among advocates shortly before the announcement and Mr. Phillips discussed the release of the implementation plan via recorded video, published to the federal government’s HIV.gov blog.

Significantly, the implementation plan details more than 380 action items from 10 different federal agencies and specifically adds focus issues of quality of living among people living with HIV/AIDS (PLWHA) which will be added to the Medical Monitoring Project’s data tables in 2023. Many of the action items detailed include education and outreach and coordination of efforts between affected federal agencies and state partners. Much of this work intersects with the Biden Administration’s efforts to address health equity and disparities, given the disproportionate representation of marginalized communities affected by HIV.

For most advocates, the announcement was a “mixed-bag” of good news and frustration at planning that primarily highlights assessments and monitoring where data may already exist or where advocates have already outlined more concrete steps they wish the federal government to take. For example, advocates and the federal government is well-aware that thanks to the advancements in quality of medications to treat HIV and being able to keep more patients engaged in care, the population of PLWHA is generally much older than they were in say…2000. However, our planning and supports for this aging population is not sufficiently strong. Medicare integration and coverage of support services specific to PLWHA is lacking and the federal government has had to engage in repeated enforcement actions against skilled nursing facilities and assisted living facilities, both regarding the refusal to provide services to PLWHA and the failure to have adequate services for PLWHA in the facility’s care.

The new quality of life metrics focus on issues of mental health, behavioral health support, food insecurity, unemployment, and unstable housing for PLWHA, with the last 3 items being considered “structural/subsistence” issues for patients. These items are arguably significantly intertwined and success or failure in any may implicate success or failure in all of these items.

In order for the federal government’s efforts to meaningfully move forward, these plans should be treated as a roadmap, rather than actions themselves. One of the things we are very good at in HIV is planning and processing. Where efforts tend to fall short is in implementation and in order to improve implementation, we need to identify if those failures to implement are due to lack of appropriate resources, expertise, or conflicting federal and state policies and priorities. Advocates should seek to hold our friends at ONAP and other agencies accountable to proactive action in defending the rights of PLWHA as patients and acting on appropriate integration of care for our aging colleagues and friends – both in terms of ensuring existing entities serving an aging population are aware of how to care for PLWHA and in ensuring entities serving PLWHA are adequately supported to care for an aging population.

In assessing effective uses of limited resources and the plan’s goals toward meeting these quality of life metrics, advocates and the federal government should consider how to leverage the Ryan White program as a workforce development and employment opportunity in order to help lift patients and highly affected communities out of poverty and, in so doing, addressing the other listed quality of life metrics. The 2021 (fiscal year) budget for the Ryan White program is $2.4 billion (not including AIDS Drug Assistance Programs). Those dollars, when focused on employing people living with and at risk for HIV, those who would otherwise be or are already Ryan White clients, would provide a significant opportunity to address these quality of life concerns and meaningfully put these dollars to use in the community the funds are meant to serve.

Rising Morbidity: Viral Hepatitis Co-Infection with HIV and Age All Associated with Increased Rates of Liver Cancer

In February, researchers associated with numerous universities across Canada and the United States published one of the most comprehensive data reviews thus far conducted on the incidence rates of the most common type of liver cancer among people living with HIV/AIDS (PLWHA) and PLWHA co-infected with viral hepatitis. The study reviewed data collected as part of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), conducted between 1996 and 2015, with clinical data from 109,283 participants. Conclusions from the study were fairly straight-forward: the combination of HIV status (mono-infection), co-infection with viral hepatitis (HBV and/or HCV) and age all correlated with an increased chance of developing liver cancer (hepatocellular carcinoma [HCC]). The hope of researchers, as evidenced in the study’s introduction was to “inform expectations for other regions with a substantial burden of HIV and HBV-HCV coinfection but with delayed cART [combination antiretroviral therapy] scale-up and limited access to viral hepatitis treatment”.

While most research papers wait to include study limitations at the end, I prefer to open with them as prefacing allows for contextualizing data. The first and primary limitation on the review is clinical information reviewed was necessarily from those people linked to care and correlations provided by the data in the study cannot be applied to the diagnosed-but-not-in-care or undiagnosed population. Second, researchers note, information on relevant, individual health factors were missing from significant portions of participants data (example: smoking and drinking habits, natural clearance of HCV, fibrosis score, and HIV exposure risk). Additionally, data collection was not uniform across all participating entities at the time of linkage to care, though a quality analysis was used to help even things out and ensure the integrity of data comparisons. This lack of uniform protocol also included certain sites not administering or participants not receiving HCV or HBV screening. The last, though likely most significant limitation of the study is the data were collected prior to the advent of curative direct acting agents (DAAs) for HCV, and conclusions cannot be made on the potential positive impacts of readily available DAAs.

A limitation not mentioned and data unassessed is any reference between older ART regimens and newer ones, in which toxicity and tolerability is commonly known to be considerably improved with newer regimens. Liver health monitoring is fairly standard, among other relevant patient labs, for PLWHA because of a relationship between ART and liver health. While it’s understandable researchers who generally enjoy significant funding from manufacturers may wish to avoid broaching this topic, not mentioning the issue, even to say “we can’t make any conclusions on cART tolerability and toxicity as an indicator for adherence or risk of developing HCC” misses an incredibly important elephant in the room for researchers, providers, and patients alike.

Instead, researchers chose to focus on cART “eras” (1996-2000 [A], 2001-2005[B], and 2006-2015[C]), in which there’s a positive correlation between age and era; or those aging with HIV were more likely to be diagnosed with HCC. Highest rates of HCC diagnosis by cART area are as follows: A – between 50 and 60 years-old (HBV co-infection with HIV), B – lower end 70-80 (HCV co-infection with HIV), and C – upper end 70-80 (HCV and HBV co-infection with HIV). This data is particularly valuable on its own, however, as the associated risk cohort shift appears to be very closely related to age (ie. those in the upper end of the C “era” are also those to first receive effective cART and the 20-year age gap between the C and A cART eras).

Ultimately, PLWHA were more than 3 times as likely as the general population to develop HCC and more than 20 times more likely to develop HCC if co-infected with viral hepatitis. HCC incidence among study participants fell along rather predictable lines in terms of HIV related clinical monitoring metrics; those with higher viral loads and lower CD4 counts were more likely to develop HCC.

The study’s finding highlight the need for ensuring access to DAAs and HBV vaccines, ready ART uptake upon linkage to care, and strengthening the integrity of AIDS Drug Assistance Programs, Medicaid Programs, and care provided to incarcerated persons – specifically, ensuring the inclusion of coverage of DAAs in these.

Advocates, providers, and patients can review DAA coverage inclusion in ADAPs and Medicaid and harm reduction policies impacting HIV and HCV with Community Access National Network’s quarterly HIV-HCV Co-Infection Watch report.