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.
Navigating the Intersection of HIV and Reproductive Cancers
As we continue to confront the challenges posed by HIV, it becomes increasingly important to address its complex interplay with other critical health issues. One such area, often overshadowed yet vitally important, is the intersection of HIV and reproductive and sexual health cancers. Just as we have seen with the resurgence of congenital syphilis, revealing significant gaps in our healthcare system, the rising concerns around HIV-associated cancers call for a similar, urgent response.
Understanding the Increased Risk
People living with HIV may face a heightened risk for various cancers, particularly those affecting reproductive and sexual health. This increased risk is not just a statistical concern but a pressing health issue that demands attention and action.
Cervical Cancer in People with HIV: A study published in The Lancet Global Health sheds light on the alarming rate at which people living with HIV (PLWH) are affected by cervical cancer. The research found that PLWH are three times more likely to develop cervical cancer compared to their HIV-negative counterparts. This is particularly concerning given the global prevalence of cervical cancer and the challenges in accessing regular screenings and human papillomavirus (HPV) vaccinations in many regions.
Prostate Cancer in People Living with HIV: A significant initiative led by the Icahn School of Medicine at Mount Sinai, funded by a $3.4 million grant from the National Cancer Institute, focuses on enhancing prostate cancer treatment for PLWH. This pioneering research employs advanced computer modeling to better understand how prostate cancer progresses and responds to treatments in PLWH. As prostate cancer is anticipated to be the most commonly diagnosed cancer in those living with HIV in the coming decade, this collaborative effort, which includes partnerships with renowned institutions like The University of Texas MD Anderson Cancer Center and Yale University School of Medicine, marks a crucial advancement in developing personalized and effective treatment strategies for this group.
Anal Cancer Considerations: Anal cancer, closely linked with HPV infection, poses a significant health concern, particularly for PLWH. Research underscores the heightened risk of anal cancer in this group, necessitating vigilant screening and early intervention. The ANCHOR study, as reported in POZ, revealed that proactive screening and treatment of anal neoplasia reduced the risk of invasive anal cancer by 57%. This parallels the successful reduction in cervical cancer through similar measures. Moreover, recent advancements in treatment, such as the use of topical trichloroacetic acid (TCA), offer effective and less painful alternatives to traditional methods like electrocautery, making treatment more accessible and tolerable. The critical role of HPV vaccination in preventing anal cancer, as discussed in research from Infectious Disease Special Edition (IDSE), cannot be overstated, especially given the lower vaccination rates among PLWH. This underscores the need for increased awareness and vaccination efforts, including for adults beyond the standard recommended age, to mitigate this risk effectively.
The Role of HAART: The introduction of Highly Active Antiretroviral Therapy (HAART) has significantly improved the life expectancy of PLWH. However, as noted in the NCBI article, this increased longevity also means a greater likelihood of developing cancers typically associated with aging, including those related to reproductive and sexual health.
The Need for Vigilant Screening and Early Detection
The research we've reviewed not only highlights the increased risk of certain cancers in PLWH but also underscores the critical importance of regular health screenings and proactive measures. These are not just routine checks; they are vital tools in the early detection and management of potentially life-threatening conditions.
PAP Smears for Cervical Cancer: Regular PAP smears are essential for PLWH assigned female at birth. The study reported by AIDSMap from South Africa illustrates the heightened risk of cervical cancer in this group. Early detection through PAP smears can lead to timely interventions, significantly improving outcomes.
Prostate Health Checks: For PLWH assigned male at birth, prostate health checks are crucial. The research discussed by OncLive emphasizes the importance of regular screening for prostate cancer. Given the unique challenges faced by PLWH, these screenings can play a key role in early detection and effective management of prostate cancer.
Anal Cancer Screening: The importance of screening and early treatment for anal cancer in PLWH, as discussed in the POZ article, cannot be overstated. Regular screenings can lead to early detection, which is crucial for effective treatment and better health outcomes.
HPV Vaccination: A Crucial Preventive Strategy for People Living with HIV
The Human Papillomavirus (HPV) vaccine plays a pivotal role in cancer prevention, especially for PLWH. The interaction between HPV and HIV significantly increases the risk of HPV-related cancers, making vaccination a key preventive measure.
Expanded Vaccination Recommendations: The Centers for Disease Control and Prevention (CDC) advises routine HPV vaccination for everyone through age 26 years if they were not adequately vaccinated earlier. For those aged 27 through 45 years, vaccination is recommended based on a discussion with their healthcare provider, particularly for those who have not been exposed to all HPV types targeted by the vaccine.
Efficacy and Safety: Research consistently shows the HPV vaccine to be safe and effective for PLWH, offering protection against several high-risk HPV strains linked to cancer. The immunogenicity of the quadrivalent HPV (qHPV) vaccine among PLWH demonstrates its effectiveness in eliciting an immune response against cancer-associated HPV types.
Cancer Risk Reduction: The HPV vaccine significantly lowers the incidence of anal high-grade squamous intraepithelial lesions (HSIL), precursors to anal cancer. This is particularly crucial for PLWH, who face a higher risk of developing anal cancer.
Challenges in Vaccination Uptake: Despite the vaccine's benefits, vaccination rates among PLWH are lower than ideal. A study presented at IDWeek 2023 by Dr. Tat Yau from LSU Health New Orleans highlights this gap: only 71% of patients under 27 in the HIV outpatient program completed their HPV vaccination series, and among those aged 27 to 45, just 38% had completed the series. This underscores the need for heightened awareness and improved access to HPV vaccination for adults living with HIV, especially those who may have missed earlier vaccination opportunities.
Vaccination Guidelines: HPV vaccination is recommended for all, including PLWH ideally before the onset of sexual activity. However, vaccination remains beneficial for those already sexually active or previously exposed to HPV.
Overcoming Barriers to Vaccination: Enhancing HPV vaccination rates among PLWH requires addressing barriers such as limited awareness, vaccine misconceptions, and access challenges. Healthcare providers are instrumental in educating patients on the vaccine's benefits and ensuring its availability.
Navigating the Intersection of HIV and Cancer with Comprehensive Care and Advocacy
The intersection of HIV and reproductive/sexual health cancers is complex, and it’s clear that a comprehensive, holistic approach is essential. This approach must intertwine comprehensive care with robust advocacy and awareness, ensuring that those of us living with HIV receive not only the best medical treatment but also holistic support that addresses our psychological, social, and emotional needs.
Holistic and Patient-Centered Care: Embracing a holistic approach means providing psychological support, social services, and emotional guidance to help patients navigate the dual challenges of HIV and cancer. Patient-centered care, which respects each person's unique needs and preferences, is fundamental. This involves open communication, active involvement in decision-making, and tailored support services, ensuring that every person's journey is navigated with dignity and resilience.
The Imperative of Regular Screenings and Proactive Healthcare: Regular health screenings, such as PAP smears, prostate exams, and HPV vaccinations, are lifesaving tools in early detection and effective treatment. Staying informed about the latest research and advancements in cancer treatment associated with HIV is crucial for both patients and healthcare providers, fostering a proactive stance in healthcare management.
Advocacy for Enhanced Access and Awareness: Advocacy is crucial in raising awareness about the increased cancer risks among PLWH and ensuring access to the latest treatments and preventive measures. This includes striving for policy changes, securing research funding, and enhancing healthcare systems, all in line with President Biden's Cancer Moonshot initiative. The initiative's goals of reducing cancer death rates, improving patient experiences, and addressing inequities in cancer care resonate deeply with the needs of the HIV community. Community engagement in these efforts is vital for reducing stigma, sharing accurate information, and empowering people in their healthcare journey. By aligning with the Cancer Moonshot's vision, we can make significant strides in improving health outcomes and quality of life for those living at the intersection of HIV and cancer. Advocates and educators should be mindful of intersecting interests in the policy space which might impact the innovation imaged by the Cancer Moonshot or might ultimately reduce access to innovations in care by payor burdens.
Our collective action, informed by the latest research and grounded in empathy and advocacy, is key to advancing the health and well-being of PLWH. We must also be mindful of systemic barriers which disempower individual access to preventative care. By addressing the intersection of HIV and these cancers effectively, we can work towards a future where this intersection is navigated with knowledge, care, and unwavering support.
Let's commit to being vigilant in our health practices, advocating for ourselves and others, and fostering a community of support and awareness. In doing so, we not only improve our health outcomes but also contribute to a broader movement towards health equity and empowerment.