Spectrum of HIV/AIDS related cancers in India

Health literacy in communication, decision-making and outcomes among cancer patients, their families and clinicians in India: A multicentre cross-sectional qualitative study

OBJECTIVE

Cancer patients in India prefer full information regarding diagnosis and prognosis, but evidence suggests poor insight. This study aimed to identify the role of health literacy among adult patients living with cancer, their families and health professionals in decision-making and treatment outcomes in India.

METHODS

This cross-sectional in-depth study recruited patients, families and clinicians from three centers. Inductive thematic analysis informed a novel conceptual model.

RESULTS

We recruited n = 34 cancer patients, n = 33 family members, n = 11 doctors and n = 14 nurses (N = 92). Principle emergent themes were the following: (1) Preferences and dynamics of diagnosis and prognosis disclosure, for example, the dominant preference was for families who held hope for cure to discourage disclosure; clinicians sometimes disclosed in line with perceived ability to pay for treatment. (2) Understanding of disease and its treatment options (etiology, potential trajectory, treatment options), for example, lay understandings of cancer etiology as contamination from outside the home, and reluctance of patients to ask questions of clinicians. (3) Priorities in decision-making, for example, not engaging patients due to fear of patient distress, patients initiated on anticancer treatments without knowledge or consent, pursuing futile treatments. (4) Anxieties over finances and outcomes (disclosure, decision-making, care pathways), for example, clinicians attempting to reduce families pursuing expensive and inappropriate treatment options with patients who have poor insight, catastrophic spending based on poor decisions.

CONCLUSION

The novel evidence-based health literacy model offers potential for feasible and acceptable intervention to support families in communication, disclosure and decision-making. This may improve patients' access to informed, appropriate care pathways.

Epidemiology of haematological malignancies in people living with HIV

People living with HIV or AIDS are at increased risk of Hodgkin and non-Hodgkin lymphoma compared with HIV-negative individuals. Data on the risk of multiple myeloma or leukaemia are inconsistent and of low quality but the risk does not seem to be increased. Specific haematological malignancies occur in different contexts of age, CD4 cell count, HIV control, viral co-infections, or chronic inflammation, and the expansion of combination antiretroviral therapy has led to varied demographic and epidemiological shifts among people with HIV. Increased use of combination antiretroviral therapy has substantially reduced the risks of diffuse large B-cell lymphoma, Burkitt lymphoma, and primary CNS lymphoma, and to a lesser extent, Hodgkin lymphoma. There is no effect of combination antiretroviral therapy use on multiple myeloma or leukaemia. Although many cases of HIV are in low-income and middle-income countries, high-quality epidemiological data for haematological malignancies from these regions are scarce. Closing this gap is an essential first step in decreasing mortality from HIV-associated haematological malignancies worldwide. Finally, although multicentric Castleman disease is not a neoplastic condition, it is an emerging precursor to neoplastic high-grade B-cell lymphoproliferation among people with HIV, especially for individuals on long-term combination antiretroviral therapy with well controlled HIV.

Cancer spectrum in HIV-infected patients: A zonal hospital experience in Tanzania

BACKGROUND

Although the burden of human immunodeficiency virus (HIV) infection in Tanzania is high, limited data are available on cancers in HIV-infected patients. We aimed to determine the spectrum and prevalence of cancers in HIV-infected patients attending care at a zonal hospital in Tanzania.

MATERIALS AND METHODS

Clinical records of HIV-infected patients from 2009 to 2019 were identified and retrospectively reviewed.

RESULTS

A total of 3398 HIV-infected patients were recruited with median age of 37 years. Cancer was diagnosed in 9% of the patients after enrollment into HIV clinical care, with an increasing prevalence from 7.2% between years 2009 and 2013 to 8.6% between years 2017 and 2019 (p-value <0.0001). Majority (89.2%) were on antiretroviral therapy (ART) during the time of cancer diagnosis. The proportions of acquired immunodeficiency syndrome (AIDS)-defining cancers and non-AIDS defining cancers were 28% and 72% respectively. Kaposi's sarcoma was the most common (13.2%) AIDS-defining cancer while esophageal cancer was the most common (11.1%) non-AIDS defining cancer. The median duration of time from HIV infection to cancer diagnosis was 715 days (IQR: 98-2570). The median CD4⁺T-cell count was 318(IQR 159-690) cells/µl at the time of cancer diagnosis and 40.7% of the patients had advanced immunosuppression with CD4 count less than 200 cells/µl at the time of cancer diagnosis.

CONCLUSION

Non-AIDS defining cancers were much more common than AIDS-defining cancers suggesting increased longevity due to ART access. The prevalence of cancer among HIV-infected patients was 9% with an increasing trend over time; highlighting the importance of promoting cancer screening in this vulnerable population and implementation of vaccinations programs for liver and cervical cancers as well as tobacco control policies for smoking-related cancers.

HIV/AIDS-related lymphoma: perspective from a regional cancer center in India

Background

India has the third largest population of people living with HIV/AIDS (PLHA). Lymphoma is the second most common malignancy among PLHA. However, data are lacking regarding HIV/AIDS-related lymphoma (ARL) in India. This study evaluated the epidemiology and clinical outcomes of ARL from a regional cancer center in India.

Methods

This retrospective analysis included cases of ARL between March 2011 and September 2017. Data were obtained from patient record files for the assessment of epidemiology and clinical outcomes. Statistical analysis was performed using GraphPad Prism 6. Comparisons of subtype-specific survivals were performed using log-rank tests.

Results

Of 1,226 lymphoma cases, 80 (6.5%) were ARL. Details were available for 70 patients. The median age at diagnosis was 40.5 (9–74) years with a male:female ratio of 2:1. AIDS-defining lymphomas (ADL) constituted 78.6% of cases, while 21.4% had non-AIDS defining lymphoma (NADL). The mean CD4 counts were 193.15±92.85 and 301.93±107.95 cells/µL, respectively (t-test; P=0.0002). Extranodal involvement was present in 55.7%, B symptoms were reported in 60%, and lactate dehydrogenase (LDH) was elevated in 64.3% of patients. The median overall survival times were 6 months for plasmablastic lymphoma (PBL), 23 months for diffuse large B-cell lymphoma (DLBCL), and was not reached for Hodgkin's lymphoma (log-rank test; P=0.0011). Other histological subtype cases were too few to draw meaningful survival outcomes.

Conclusion

ARL is a heterogeneous disease. Histologic subtype is a major determinant of the clinical outcome. ADL has significantly lower CD4 counts than those of NADL. There is an urgent and unmet need for uniform management guidelines for improving outcomes in this under-represented patient population.

Gynecologic cancer in HIV-positive women: a systematic review and meta-analysis

BACKGROUND

While there is a significant body of literature on cervical cancer in HIV-positive women, little is known about other gynecologic cancers in this population.

OBJECTIVE

The objective of this systematic review and meta-analysis is to describe the incidence, presentation, treatment, and outcomes for HIV-positive women with non-acquired immunodeficiency syndrome-defining gynecologic cancers.

STUDY DESIGN

We searched MEDLINE, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials for English-language studies published from 2000 to May 1, 2017. Studies containing 1 or more HIV-positive women with endometrial, ovarian, or vulvovaginal cancer and reporting incidence, treatment regimen, or survival were included. Two authors independently reviewed abstracts and full-text articles for inclusion and assessed study quality (details of the review protocol were registered as PROSPERO-CRD42017064525). Pooled estimates of incidence were calculated using random-effects models. Pooled estimates of cancer presentation and outcomes were averaged from case studies.

RESULTS

Of 5744 abstracts screened, we identified 70 articles on 58 studies on 292,202 women with HIV and 528 women with HIV and gynecologic cancer for inclusion. Most articles (53%) focused on incidence, and only 3, 4, and 20 articles focused on treatment and outcomes of endometrial, ovarian, and vulvovaginal cancers, respectively. The standardized incidence ratios for endometrial, ovarian, and vulvovaginal cancers were 4.38 (95% confidence interval 0.26-8.49) for endometrial cancer, 3.21 (95% confidence interval 2.29-4.13) for ovarian cancer, and 21.93 (95% confidence interval 13.50-30.35) for vulvovaginal cancer. Fifty-seven percent of women were diagnosed at an early stage, and all received cancer treatment.

CONCLUSION

In women with HIV, the incidence of ovarian and vulvovaginal cancer were higher than the general population, while incidence of endometrial cancer was similar. However, there was a paucity of data on treatment and outcomes for non-acquired immunodeficiency syndrome-defining gynecologic cancers. Given the increased incidence of gynecologic cancer, specific research on this population is essential to improve treatment and outcomes for HIV-positive women.

Role of Viral Infections in Testicular Cancer Etiology: Evidence From a Systematic Review and Meta-Analysis

The most represented histotype of testicular cancer is the testicular germ-cell tumor (TGCT), both seminoma and non-seminoma. The pathogenesis of this cancer is poorly known. A possible causal relationship between viral infections and TGCTs was firstly evoked almost 40 years ago and is still a subject of debate. In the recent past, different authors have argued about a possible role of specific viruses in the development of TGCTs including human papillomavirus (HPV), Epstein-Barr virus (EBV), cytomegalovirus (CMV), Parvovirus B-19, and human immunodeficiency virus (HIV). The aim of this present review was to summarize, for each virus considered, the available evidence on the impact of viral infections on the risk of developing TGCTs. The review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included all observational studies reported in English evaluating the correlations between viral infections (HPV, CMV, EBV, Parvovirus B19, and HIV) and TGCTs. The methodological quality of studies included in the meta-analysis was evaluated using a modified version of the "Newcastle-Ottawa Scale." Meta-analyses were conducted using the "Generic inverse variance" method, where a pooled odds ratio (OR) was determined from the natural logarithm (LN) of the studies' individual OR [LN (OR)] and the 95% CI. A total of 20 studies (on 265,057 patients) were included in the review. Meta-analysis showed an association with TGCTs only for some of the explored viruses. In particular, no association was found for HPV, CMV, and Parvovirus B-19 infection (p = ns). Conversely, EBV and HIV infections were significantly associated with higher risk of developing TGCTs (OR 7.38, 95% CI 1.89-28.75, p = 0.004; OR 1.71, 95% CI 1.51-1.93, p < 0.00001). In conclusion, we found adequate evidence supporting an oncogenic effect of HIV and EBV on the human testis. Conversely, available data on HPV and TGCTs risk are conflicting and further studies are needed to draw firm conclusions. Finally, current evidence does not support an effect of CMV and Parvovirus B-19 on testicular carcinogenesis.

Human papillomavirus infection & anal cytological abnormalities in HIV-positive men in eastern India

Background

Oncogenic Human papillomavirus (HPV) infections are closely associated with anal cancer which is high among human immunodeficiency virus (HIV) infected males. There are no data regarding anal HPV infection and cytological abnormalities in HIV positive males receiving free therapy in the national program. Thus, this cross-sectional study was performed to assess the prevalence and risk factors of anal HPV infection and cytological abnormalities in HIV positive males.

Methods

We screened 126 HIV-positive male patients attending the antiretroviral treatment center (ART) between 2014 and 2015 with anal papanicolaou smear cytology and HPV-DNA testing. HPV-DNA was detected by using polymerase chain reaction (PCR) method with two consensus primer sets E6 and MY09/11 and further analyzed for the presence of various HPV genotype by Sanger sequencing. Risk factors associated with anal cytological abnormalities and HPV infection was analyzed by using univariate and multivariate logistic regression models.

Results

Out of 126, 52 were on antiretroviral therapy. 91% were married to female partners but during the study 48 (38%) gave positive history of anal intercourse with other men. Anal cytology was done in 95 patients, out of which 60 (63.15%) had cytological abnormalities. LSIL (low-grade squamous intraepithelial lesions) was present in 27 (45%), ASCUS (atypical squamous cells of undetermined significance) in 31 (52%) and ASC-H (atypical squamous cells cannot exclude a high-grade squamous intraepithelial lesion) in 2 (3.33%). In multivariate analysis, the risk factors for cytological abnormality were presence of history of anal intercourse (OR, 6.1; 95% CI, 2.0–18.7) and WHO stage III & IV (OR, 2.7; 95% CI, 1.1–7.5). HPV-DNA was detected in 33/119 (27.73%) patients. The most prevalent HPV type in the study was HPV-16 (10.08%), other HPV types detected were 18,31,35,17,66,72,52,68 and 107 (17.65%).

Conclusions

High prevalence of anal cytological abnormalities in our study suggests that regular anal Pap smear screening should be done in HIV positive males in the ART center.

Comprehensive cancer control-research & development: knowing what we do and doing what we know

Comprehensive cancer control is defined as an integrated and coordinated approach to reducing cancer incidence, morbidity, and mortality across the cancer control continuum from primary prevention to end-of-life care. This approach assumes that when the public sector, non-governmental organizations, academia, and the private sector share with each other their skills, knowledge, and resources, a country can take advantage of all its talents and resources to more quickly reduce the burden of cancer for all its population. One critical issue for comprehensive cancer control is the extent to which the private sector can contribute to cancer prevention and control programs and policies that have historically been lead by the public health sector, and similarly how can the public sector increase its investment and involvement in clinical research and practice issues that are largely driven by the private sector worldwide?

In addition, building capacity to integrate research that is appropriate to the culture and context of the population will be important in different settings, in particular research related to cancer control interventions that have the capacity to influence outcomes. To whatever extent cancer control research is ultimately funded through the private and public sectors, if investments in research discoveries are ultimately to benefit the populations that bear the greatest burden of disease, then new approaches to integrating the lessons learned from science with the lessons learned from service (public health, clinical, and public policy) must be found to close the gap between what we know and what we do. Communities of practice for international cancer control, like the ones fostered by the first three International Cancer Control Congresses, represent an important forum for knowledge exchange opportunities to accelerate the translation of new knowledge into action to reduce the burden of cancer worldwide.

Prevalence of HIV in Patients with Malignancy and of Malignancy in HIV Patients in a Tertiary Care Center from North India

BACKGROUND AND OBJECTIVES

People living with HIV/AIDS are at an increased risk of developing cancer. The goals of this study were to obtain data on the prevalence of HIV in the cancer population and vice versa at a major tertiary cancer and HIV center in North India.

METHODS

This cross-sectional study was conducted over a 3-year period from July 2013 to June 2016, wherein successive HIV positive patients from an anti-retroviral therapy (ART) center were screened for malignancy. Simultaneously, successive cancer patients at the cancer center were screened for HIV. Baseline demographic details, risk factors, and laboratory investigations were obtained for all the patients.

RESULTS

Among the 999 HIV-positive patients at the ART center, the prevalence of malignancy was 2% (n=20; 95% confidence interval (CI) 1.13, 2.87). Among the 998 patients with a malignancy, the prevalence of HIV infection was 0.9% (n=9; 95% CI 0.31, 1.49). Weight loss, loss of appetite, and fever were the most common symptoms in patients with HIV and cancer. Among 29 patients with HIV and cancer, AIDS-defining cancer was found in 19 patients; non-Hodgkin's lymphoma was the most common malignancy reported (n=13).

INTERPRETATION AND CONCLUSION

There is a low prevalence of HIV in cancer patients as well as a low prevalence of cancer in HIV patients. AIDS-defining cancers remain much more common than non-AIDS-defining cancers. With the increased coverage of ART, it is expected that non-AIDSdefining cancers will increase, as is evident from data from more developed countries.

Genital Human Papillomavirus Infection in Indian HIV-Seropositive Men Who Have Sex With Men

BACKGROUND

The incidence of penile cancer in Indian men is high. Little is known about genital human papillomavirus (HPV) infection in Indian HIV-seropositive men who have sex with men (MSM), a population that may be at particularly high risk for genital HPV infection and, potentially, penile cancer. In this study, we assessed the prevalence and risk factors for genital HPV infection in this population.

DESIGN AND METHODS

Three hundred HIV-seropositive MSM were recruited from 2 clinical sites in India. They were tested for genital HPV infection using L1 HPV DNA polymerase chain reaction with probes specific for 29 types and a mixture of 10 additional types. Participants received an interviewer-administered questionnaire that included questions on demographics and behaviors.

RESULTS

Human papillomavirus data were available from 299 participants. The prevalence of any HPV type in the penis and scrotum was 55% and 54%, respectively. Human papillomavirus type 35 was the most common oncogenic HPV type followed by HPV-16. In multivariate analysis, being the insertive partner with 100+ male partners increased the odds of any penile HPV infection compared with not being insertive with any partners (odds ratio, 2.5; 95% confidence interval, 1.3-5.1). Circumcision was protective against penile HPV infection (odds ratio, 0.39; 95% confidence interval, 0.19-0.76).

CONCLUSIONS

The prevalence of penile and scrotal HPV infection was high among Indian HIV-seropositive MSM. The most common oncogenic HPV type in this population, HPV-35, is not included in any currently available HPV vaccines. Insertive anal sex with men and lack of circumcision were the primary risk factors for penile HPV infection in this population.

Spectrum of AIDS defining & non-AIDS defining malignancies in north India

Background & objectives:

There is scarcity of data on the frequency of malignancies in HIV infected individuals from India. The objective of this study was to determine the type and frequency of malignancies in HIV infected individuals attending a tertiary care hospital in north India.

Methods:

The study design included retrospective analysis of data of all HIV infected individuals registered in the Immunodeficiency clinic from December 2009 to December 2011 and a prospective analysis of HIV infected individuals registered from January 2012 to April 2013. The clinical details and treatment outcomes of all individuals diagnosed to have AIDS defining and non-AIDS defining malignancies were recorded.

Results:

Records of 2880 HIV infected individuals were reviewed. Thirty one (19 males, 12 females) individuals were diagnosed to have malignancy. AIDS defining malignancy was found in the form of non-Hodgkin's lymphoma in 12 individuals and cervical cancer in six women. Non-AIDS defining malignancies included Hodgkin's lymphoma (n=2); and chronic myelogenous leukaemia, carcinoma base of tongue, carcinoma larynx, carcinoma bronchus, sinonasal carcinoma, ovarian carcinoma, anal carcinoma, carcinoma urinary bladder, pleomorphic sarcoma, parathyroid adenoma, and renal cell carcinoma in one individual each. Mean CD4+cell count prior to ART initiation was 250 ± 195.6 (median: 187; range, 22-805) cells/μl and at the time of diagnosis of malignancy was 272 ± 202 (median: 202; range, 15-959) cells/μl. The mean CD4+ count of individuals with AIDS defining malignancy was significantly lower when compared with non-AIDS defining malignancy (P<0.001). Fourteen individuals were alive and on regular follow up, 15 had died and two cases were lost to follow up.

Interpretation & conclusions:

The frequency of malignancies in HIV infected patients at our centre was 1 per cent, with non-Hodgkin's lymphoma being the commonest. Further studies need to be done to document similar data from different parts of the country.

Overview of cancer incidence and mortality among people living with HIV/AIDS in British Columbia, Canada: Implications for HAART use and NADM development

Background

The objective of this study is to evaluate the incidence of non-AIDS defining malignancies (NADMs) among people living with HIV/AIDS (PLWHA) in British Columbia, focusing on clinical correlates, highly active antiretroviral therapy (HAART) use, and survival, in order to elucidate mechanisms for NADM development.

Methods

A retrospective population based analysis was carried out for individuals with HIV/AIDS that began their treatment between 1996 and 2008.

Results

There were 145 (2.95%) NADMs and 123 (2.50%) AIDS defining malignancies (ADMs) identified in 4918 PLWHA in the study population. NADMs were represented by a range of cancer types including, most commonly, lung cancer, followed by anal, breast, head/neck, prostate, liver, rectal, and renal cancers. PLWHA had a SIR of 2.05 (CI:1.73, 2.41) for the development of NADMs compared to individuals without an HIV/AIDS diagnosis in the general population. Independent factors significantly associated with a NADM were: male gender, older age, lower CD4 cell counts, previous NADM, absence of HAART (non-HAART versus HAART) and treatment during the early-HAART era (before 2000 versus after 2000).

Conclusions

NADMs represent an important source of morbidity for PLWHA. Use of HAART with its associated improvement in immune-restoration, and tailored targeted cancer screening interventions, may be beneficial and improve outcomes in this unique patient population.

Malignancies in human immunodeficiency virus infected patients in India: Initial experience in the HAART era

Background & objectives:

Limited data are available on malignancies in human immunodeficiency virus (HIV)-infected patients from India. We undertook this study to assess the frequency and spectrum of malignancies in HIV-infected adult patients during the first eight years of highly active antiretroviral therapy (HAART) rollout under the National ART Programme at a tertiary care centre in New Delhi, India.

Methods:

Retrospective analysis of records of patients registered at the ART clinic between May 2005 and December 2013 was done.

Results:

The study included 2598 HIV-infected adult patients with 8315 person-years of follow up. Malignancies were diagnosed in 26 patients with a rate of 3.1 (IQR 2.1-4.5) cases per 1000 person-years. The median age for those diagnosed with malignancy was 45 (IQR 36-54) yr, which was significantly (P<0.01) higher compared with those not developing malignancies 35 (IQR 30-40) yr. The median baseline CD4+ T-cell count in patients with malignancy was 135 (IQR 68-269) cells/µl compared to 164 (IQR 86-243) cells/µl in those without malignancies. AIDS-defining cancers (ADCs) were seen in 19 (73%) patients, while non-AIDS-defining cancers (NADCs) were observed in seven (27%) patients. Malignancies diagnosed included non-Hodgkin's lymphoma (16), carcinoma cervix (3), Hodgkin's lymphoma (2), carcinoma lung (2), hepatocellular carcinoma (1), and urinary bladder carcinoma (1). One patient had primary central nervous system lymphoma. There was no case of Kaposi's sarcoma.

Interpretation & conclusions:

Malignancies in HIV-infected adult patients were infrequent in patients attending the clinic. Majority of the patients presented with advanced immunosuppression and the ADCs, NHL in particular, were the commonest malignancies.

HIV-associated hematologic malignancies: Experience from a Tertiary Cancer Center in India

Context and Aim:

Data on HIV associated hematologic malignancies is sparse from India. This study attempts to analyze the spectrum and features of this disease at a tertiary cancer center in India.

Setting and Methods:

Retrospective study from case records of patients registered with a diagnosis of hematologic malignancy and HIV infection between January 2010 and June 2015.

Results:

Thirteen cases of HIV associated hematologic malignancies were identified, six of them pediatric. HIV diagnosis was concurrent to diagnosis of cancer in 12 and preceded it in one of them. ECOG PS at presentation was >1 in all of them. All patients, except one, had B symptoms. Six of the patients had bulky disease and six are stage 4. Predominant extranodal disease was seen in 67% of them. NHL accounted for 10 of 13 patients and DLBCL-Germinal center was the most common subtype. Mean CD4+ cell count was 235/μL (range, 32-494). HAART could be given along with chemotherapy to 11 patients. Two-thirds of patients received standard doses of therapy. Chemo-toxicity required hospitalization in 58%. CR was achieved in 45% and 36% had progressive disease with first-line therapy. At the time of last follow up, 3 patients were alive with responsive disease, 2 in CR and 1 in PR. None of the pediatric patients were long time responders.

Conclusions:

These malignancies were of advanced stage and higher grade. Goal of therapy, in the HAART era, is curative. Pediatric patients had dismal outcome despite good chemotherapy and HAART. There is an urgent need to improve data collection for HIV related cancers in India.

HIV and cancer registry linkage identifies a substantial burden of cancers in persons with HIV in India

We utilized computerized record-linkage methods to link HIV and cancer databases with limited unique identifiers in Pune, India, to determine feasibility of linkage and obtain preliminary estimates of cancer risk in persons living with HIV (PLHIV) as compared with the general population.Records of 32,575 PLHIV were linked to 31,754 Pune Cancer Registry records (1996-2008) using a probabilistic-matching algorithm. Cancer risk was estimated by calculating standardized incidence ratios (SIRs) in the early (4-27 months after HIV registration), late (28-60 months), and overall (4-60 months) incidence periods. Cancers diagnosed prior to or within 3 months of HIV registration were considered prevalent.Of 613 linked cancers to PLHIV, 188 were prevalent, 106 early incident, and 319 late incident. Incident cancers comprised 11.5% AIDS-defining cancers (ADCs), including cervical cancer and non-Hodgkin lymphoma (NHL), but not Kaposi sarcoma (KS), and 88.5% non-AIDS-defining cancers (NADCs). Risk for any incident cancer diagnosis in early, late, and combined periods was significantly elevated among PLHIV (SIRs: 5.6 [95% CI 4.6-6.8], 17.7 [95% CI 15.8-19.8], and 11.5 [95% CI 10-12.6], respectively). Cervical cancer risk was elevated in both incidence periods (SIRs: 9.6 [95% CI 4.8-17.2] and 22.6 [95% CI 14.3-33.9], respectively), while NHL risk was elevated only in the late incidence period (SIR: 18.0 [95% CI 9.8-30.20]). Risks for NADCs were dramatically elevated (SIR > 100) for eye-orbit, substantially (SIR > 20) for all-mouth, esophagus, breast, unspecified-leukemia, colon-rectum-anus, and other/unspecified cancers; moderately elevated (SIR > 10) for salivary gland, penis, nasopharynx, and brain-nervous system, and mildly elevated (SIR > 5) for stomach. Risks for 6 NADCs (small intestine, testis, lymphocytic leukemia, prostate, ovary, and melanoma) were not elevated and 5 cancers, including multiple myeloma not seen.Our study demonstrates the feasibility of using probabilistic record-linkage to study cancer/other comorbidities among PLHIV in India and provides preliminary population-based estimates of cancer risks in PLHIV in India. Our results, suggesting a potentially substantial burden and slightly different spectrum of cancers among PLHIV in India, support efforts to conduct multicenter linkage studies to obtain precise estimates and to monitor cancer risk in PLHIV in India.

Cancer in the HIV-Infected Host: Epidemiology and Pathogenesis in the Antiretroviral Era

Cancer and HIV are inextricably linked. Although the advent of antiretroviral therapy has led to a marked decline in the incidence of malignancies classically linked to immunosuppression (AIDS-defining malignancies, or ADMs), this decrease has been accompanied by a concomitant rise in the incidence of other malignancies (non-AIDS-defining malignancies, or NADMs). Population-based cancer registries provide key information about cancer epidemiology in people living with HIV (PLWH) within resource-rich countries. The risk for NADMs is elevated in PLWH compared with the general population, particularly for lung and anal cancers. Contributory factors include tobacco use, coinfection with oncogenic viruses such as human papillomavirus, and potentially direct effects of HIV itself. Data from resource-poor countries are limited and highlight the need for more studies in countries where the majority of PLWH reside. Strategies for early cancer detection and/or prevention are necessary in PLWH.

Prevalence of Anal HPV Infection Among HIV-Positive Men Who Have Sex With Men in India

BACKGROUND

India has a large population of HIV-positive individuals, including men who have sex with men (MSM), and the incidence of human papillomavirus (HPV)-related cancers is high. In developed countries, HIV-positive MSM exhibit the highest prevalence of anal HPV infection and incidence of anal cancer. Little is known about anal HPV infection in HIV-positive Indian MSM.

METHODS

We evaluated 300 HIV-positive MSM from 2 cities in India. Men were tested for anal HPV infection using L1-HPV DNA polymerase chain reaction with probes specific for 29 types and a mixture of 10 additional types. CD4 level and plasma HIV viral load were measured. Participants completed an interviewer-administered questionnaire including a sexual history.

RESULTS

The prevalence of anal HPV was 95% (95% confidence interval: 91% to 97%). The 3 most common types were HPV 35 (20%), HPV 16 (13%), and HPV 6/11 (13%). History of taking antiretroviral medications decreased risk of anal HPV 16 infection [relative risk (RR): 0.6 (0.4-1.0)]. Having an increased number of vaginal sex partners lowered risk of any anal HPV infection. Ever having receptive sex increased risk of any anal HPV [RR: 1.2 (1.1-1.4)] and anal HPV 16 [RR: 6.5 (1.8-107)].

CONCLUSIONS

Almost all Indian HIV-positive MSM had anal HPV infection. The prevalence of HPV 16 was lower and the prevalence of other oncogenic HPV types was higher than in similar populations in North America and Europe. Vaccine-based prevention strategies for HPV infection in India should consider potential differences in HPV type distribution among HIV-infected MSM when designing interventions.

Human papillomavirus in the HIV-infected host: epidemiology and pathogenesis in the antiretroviral era

Human papillomavirus (HPV) infection is associated with essentially all cervical cancers, 80-90 % of anal cancers, and a high proportion of oropharyngeal, vaginal, penile, and vulvar cancers. Malignancy is preceded by the development of precancerous lesions termed high-grade squamous intraepithelial lesions (HSIL). Men and women with human immunodeficiency virus (HIV) infection are at high risk of HPV-related malignancies. The incidence of anal cancer in particular has markedly risen during the antiretroviral era due to the increased longevity of patients with HIV and the absence of anal malignancy screening programs. HIV infection may facilitate initial HPV infection by disrupting epithelial cell tight junctions. Once infection is established, HIV may promote HSIL development via the up-regulation of HPV oncogene expression and impairment of the immune response needed to clear the lesion. HIV-infected women should be screened for cervical HSIL and cancer, and HIV-infected men and women should be considered for anal screening programs.

Challenges in the detection, prevention, and treatment of HIV-associated malignancies in low- and middle-income countries in Africa

Cancers associated with immunosuppression and infections have long been recognized as a major complication of HIV/AIDS. More recently, persons living with HIV are increasingly diagnosed with a wider spectrum of HIV-associated malignancies (HIVAM) as they live longer on combination antiretroviral therapy. This has spurred research to characterize the epidemiology and determine the optimal management of HIVAM with a focus on low-and middle-income countries (LMICs). Given background coinfections, environmental exposures, host genetic profiles, antiretroviral therapy usage, and varying capacities for early diagnosis and treatment, one can expect the biology of cancers in HIV-infected persons in LMICs to have a significant impact on chronic HIV care, as is now the case in high-income countries. Thus, new strategies must be developed to effectively prevent, diagnose, and treat HIVAM in LMICs; provide physical/clinical infrastructures; train the cancer and HIV workforce; and expand research capacity-particularly given the challenges posed by the limitations on available transportation and financial resources and the population's general rural concentration. Opportunities exist to extend resources supported by the President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis, and Malaria to improve the health-care infrastructure and train the personnel required to prevent and manage cancers in persons living with HIV. These HIV chronic care infrastructures could also serve cancer patients regardless of their HIV status, facilitating long-term care and treatment for persons who do not live near cancer centers, so that they receive the same degree of care as those receiving chronic HIV care today.

Spectrum of malignancies among HIV-infected patients in South India

INTRODUCTION

The current study examines the spectrum of malignancies among HIV-infected South Indians enrolled in a clinical care program.

MATERIALS AND METHODS

We conducted a nested matched case-control study among 42 HIV-infected cases who developed cancer and 82 HIV-infected controls between 1998 and 2008 at a tertiary care HIV care program in South India.

RESULTS

The most common types of cancer included non-Hodgkin's lymphoma (38.1%), Hodgkin's lymphoma (16.7%), squamous cell carcinoma (14.3%), and adenocarcinoma (14.3%). The median duration of time from HIV infection to cancer diagnosis was 549 days [interquartile range (IQR): 58-2013]. The nadir CD4 cell count was significantly lower in cases compared to controls (134 cells/μl vs. 169 cells/μl; P = 0.015). Cancer patients were more likely to have a more advanced HIV disease stage at the time of cancer diagnosis compared to control patients (Stage C: 90.5% vs. 49.4%; P<0.0001). Significantly more cancer patients were receiving antiretroviral treatment relative to control patients at the time of cancer diagnosis (92.9% vs. 66.3%; P=0.001).

CONCLUSIONS

HIV-infected patients who developed cancer had more advanced immunodeficiency at the time of cancer diagnosis and a lower nadir CD4 cell count. It is possible that with the continued roll-out of highly active antiretroviral therapy in India, the incidence of HIV-associated malignancies will decrease.

The spectrum of clinical and pathological manifestations of AIDS in a consecutive series of 236 autopsied cases in mumbai, India

The HIV epidemic in the Asian subcontinent has a significant impact on India. The AIDS associated pathology has not been well evaluated in a representative study hence very little is known about the spectrum of HIV/AIDS associated diseases in Indian subcontinent. To determine the important postmortem findings in HIV infected individuals in Mumbai, autopsy study was carried out. The patient population included patients with AIDS who died at the tertiary care hospital over a 20 year period from 1988 to 2007. A total of 236 (182; 77% males and 54; 23%) females) patients with AIDS were autopsied. The main risk factor for HIV transmission was heterosexual contact (226 patients; 96%) and 223/236 (94%) patients died of HIV-related diseases. Tuberculosis was the prime cause of death in 149 (63%) patients, followed by bacterial pneumonia 33 (14%), cryptococcosis 18 (8%), toxoplasmosis of brain 15 (6%), pneumocystis jiroveci (PCJ) 1 (0.5%) and Non-Hodgkin's lymphoma 7 (3%) cases. The major underlying pathologies are either preventable or treatable conditions. There is an urgent need for attention towards the diagnosis, issue of therapy, and care of HIV disease in developing countries. Reducing mortality in patients with AIDS from infections must be highest public health policy in India.

The increasing burden of HIV-associated malignancies in resource-limited regions

Cancer is increasingly recognized as a complication of HIV infection in both resource-rich and resource-limited areas. The traditional AIDS-defining cancers, including Kaposi sarcoma, cervical cancer, and non-Hodgkin lymphoma, have become common comorbidities afflicting HIV-positive individuals and lack adequate prevention and management options. Additionally, several non-AIDS-defining cancers have increased in incidence in resource-limited regions, including Hodgkin lymphoma, hepatocellular carcinoma, and lung cancer. This review outlines the epidemiology of HIV-associated malignancies in resource-poor and resource-rich areas, including the impact of highly active antiretroviral therapy on the incidence of these cancers. The pathogenesis of HIV-associated cancers is considered in relation to potential strategies for their prevention and treatment.

Cancers in the TREAT Asia HIV Observational Database (TAHOD): a retrospective analysis of risk factors

Background

This retrospective survey describes types of cancers diagnosed in HIV-infected subjects in Asia, and assesses risk factors for cancer in HIV-infected subjects using contemporaneous HIV-infected controls without cancer.

Methods

TREAT Asia HIV Observational Database (TAHOD) sites retrospectively reviewed clinic medical records to determine cancer diagnoses since 2000. For each diagnosis, the following data were recorded: date, type, stage, method of diagnosis, demographic data, medical history, and HIV-related information. For risk factor analyses, two HIV-infected control subjects without cancer diagnoses were also selected. Cancers were grouped as AIDS-defining cancers (ADCs), and non-ADCs. Non-ADCs were further categorized as being infection related (NADC-IR) and unrelated (NADC-IUR).

Results

A total of 617 patients were included in this study: 215 cancer cases and 402 controls from 13 sites. The majority of cancer cases were male (71%). The mean age (SD) for cases was 39 (10.6), 46 (11.5) and 44 (13.7) for ADCs, NADC-IURs and NADCs-IR, respectively. The majority (66%) of cancers were ADCs (16% Kaposi sarcoma, 40% non-Hodgkin's lymphoma, and 9% cervical cancer). The most common NADCs were lung (6%), breast (5%) and hepatocellular carcinoma and Hodgkin's lymphoma (2% each). There were also three (1.4%) cases of leiomyosarcoma reported in this study. In multivariate analyses, individuals with CD4 counts above 200 cells/mm³ were approximately 80% less likely to be diagnosed with an ADC (p < 0.001). Older age (OR: 1.39, p = 0.001) and currently not receiving antiretroviral treatment (OR: 0.29, p = 0.006) were independent predictors of NADCs overall, and similarly for NADCs-IUR. Lower CD4 cell count and higher CDC stage (p = 0.041) were the only independent predictors of NADCs-IR.

Conclusions

The spectrum of cancer diagnoses in the Asia region currently does not appear dissimilar to that observed in non-Asian HIV populations. One interesting finding was the cases of leiomyosarcoma, a smooth-muscle tumour, usually seen in children and young adults with AIDS, yet overall quite rare. Further detailed studies are required to better describe the range of cancers in this region, and to help guide the development of screening programmes.

Immune reconstitution inflammatory syndrome in AIDS-related non-hodgkin's lymphoma

Immune Reconstitution syndrome following antiretroviral therapy is common in HIV/AIDS patients due to boosting of immunity. A case is reported here wherein AIDS-related Non-Hodgkin‘s lymphoma patient received CHOP regimen and antiretroviral therapy. Patient developed tubercular lymphadenopathy paradoxically as a manifestation of IRIS.

Cancer in cohort of HIV-infected population: prevalence and clinical characteristics

OBJECTIVE

To determine the incidence and survival time of acquired immunodeficiency syndrome-related malignancies among HIV-infected population.

METHODS

A clinical database search, chart review and verification with health records were undertaken for all AIDS-defining cancers diagnosed in Zhongnan Hospital Wuhan University, Hubei Province, China. Kaplan-Meier method was used to evaluate survival time in HIV-infected patients with cancer.

RESULTS

A total of 3,554 patients with 11,072 person-years of HIV follow-up care were reviewed from January 2004 to December 2008. Sixty-three cancer cases were identified. The median ages of HIV-positive cancer cases were 42.4 ± 8.8 years, CD4 count were 220.9 ± 142.3/µl. The common cancers were non-Hodgkin's lymphoma (NHL, 28.6%), cervical cancer (22.2%), liver cancer (17.5%). Statistically significantly elevated SIRs were observed in NHL (SIR in all = 34.5, 95% CI 11.7-89.9, SIR in males = 45.3, 95% CI 24.7-138.9, females = 12.2, 95% CI 3.9-38.2), invasive cervical cancer (SIR = 68.1, 95% CI 19.2-84.5), liver cancer (SIR = 6.0, 95% CI 2.6-12.2), nasopharyngeal cancer (SIR = 6.2, 95% CI 1.5-44.9), bladder cancer (SIR = 4.9, 95% CI 0.9-22.9), esophageal cancer (SIR = 3.1, 95% CI 0.7-14.3), and stomach cancer (SIR = 2.6, 95% CI 0.6-11.6). All cancers combined showed a statistically significantly elevated SIR of 4.1 (95% CI 2.5-4.6), SIR for all cancers was much higher in female (SIR = 4.8, 95% CI 3.2-7.3) than in male (SIR = 3.1, 95% CI 2.1-4.3). Among HIV-positive patients with cancer, the median survival time was 14.5 ± 3.8 months in NHL group, 28.9 ± 3.6 months in cervix group, 5.1 ± 1.1 months in liver group, and 26.7 ± 6.7 months in other groups. The median survival time in HIV-infected group (23.1 ± 3.5 months) was shorter than that in non-HIV-infected group (43.0 ± 5.1 months), (P < 0.05).

CONCLUSIONS

NHL, cervical cancers and liver cancer are common cancers among HIV-infected individuals in Hubei, China. Most malignant diseases that arise in the setting of HIV infection tend to occur at a more advanced stage with shorter survival time.

The challenge of AIDS-related malignancies in sub-Saharan Africa

BACKGROUND

With the lengthening of life expectancy among HIV-positive subjects related to the use of highly active antiretroviral treatments, an increased risk of cancer has been described in industrialized countries. The question is to determine what occurs now and will happen in the future in the low income countries and particularly in sub-Saharan Africa where more than two-thirds of all HIV-positive people live in the world. The objective of our paper is to review the link between HIV and cancer in sub-Saharan Africa, putting it in perspective with what is already known in Western countries.

METHODS AND FINDINGS

Studies for this review were identified from several bibliographical databases including Pubmed, Scopus, Cochrane, Pascal, Web of Science and using keywords "HIV, neoplasia, epidemiology and Africa" and related MesH terms. A clear association was found between HIV infection and AIDS-classifying cancers. In case-referent studies, odds ratios (OR) were ranging from 21.9 (95% Confidence Interval (CI) 12.5-38.6) to 47.1 (31.9-69.8) for Kaposi sarcoma and from 5.0 (2.7-9.5) to 12.6 (2.2-54.4) for non Hodgkin lymphoma. The association was less strong for invasive cervical cancer with ORs ranging from 1.1 (0.7-1.2) to 1.6 (1.1-2.3), whereas ORs for squamous intraepithelial lesions were higher, from 4.4 (2.3-8.4) to 17.0 (2.2-134.1). For non AIDS-classifying cancers, squamous cell conjunctival carcinoma of the eye was associated with HIV in many case-referent studies with ORs from 2.6 (1.4-4.9) to 13.0 (4.5-39.4). A record-linkage study conducted in Uganda showed an association between Hodgkin lymphoma and HIV infection with a standardized incidence ratio of 5.7 (1.2-17) although OR in case-referent studies ranged from 1.4 (0.7-2.8) to 1.6 (1.0-2.7). Other cancer sites found positively associated with HIV include lung, liver, anus, penis, vulva, kidney, thyroid and uterus and a decreased risk of female breast cancer. These results so far based on a relatively small number of studies warrant further epidemiological investigations, taking into account other known risk factors for these tumors.

CONCLUSION

Studies conducted in sub-Saharan Africa show that HIV infection is not only strongly associated with AIDS-classifying cancers but also provided some evidence of association for other neoplasia. African countries need now to implement well designed population-based studies in order to better describe the spectrum of AIDS-associated malignancies and the most effective strategies for their prevention, screening and treatment.

A meta-analysis of the incidence of non-AIDS cancers in HIV-infected individuals

OBJECTIVE

To estimate summary standardized incidence ratios (SIRs) of non-AIDS cancers among HIV-infected individuals compared with general population rates overall and stratified by gender, AIDS, and highly active antiretroviral therapy (HAART) era.

DESIGN

A meta-analysis using SIRs from 18 studies of non-AIDS cancer in HIV-infected individuals.

METHODS

SIRs for non-AIDS cancers in HIV-infected individuals and 95% confidence limits (CLs) were abstracted from each study. Random effects meta-analyses were used to estimate summary SIRs. Modifications by gender, AIDS, and HAART era were estimated with meta-regression.

RESULTS

Four thousand seven hundred ninety-seven non-AIDS cancers occurred among 625,716 HIV-infected individuals. SIRs for several cancers were elevated. In particular, cancers associated with infections, such as anal (SIR = 28; 95% CL 21 to 35), liver (SIR = 5.6; 95% CL 4.0 to 7.7), and Hodgkin lymphoma (SIR = 11; 95% CL 8.8 to 15) and smoking, such as lung (SIR = 2.6; 95% CL 2.1 to 3.1), kidney (SIR = 1.7; 95% CL 1.3 to 2.2), and laryngeal (SIR = 1.5; 95% CL 1.1 to 2.0). AIDS was associated with greater SIRs for Hodgkin lymphoma, leukemia, lung, brain, and all non-AIDS cancers combined.

CONCLUSIONS

HIV-infected individuals may be at an increased risk of developing non-AIDS cancers, particularly those associated with infections and smoking. An association with advanced immune suppression was suggested for certain cancers.

Men who have sex with men in India: a systematic review of the literature

This study systematically reviews the existing literature on sexually transmitted infections (STIs) including human immunodeficiency virus (HIV) infection in the men who have sex with men (MSM) in India. After a comprehensive literature search of Medline (1950-June 2008), Embase (1980-June 2008), and the Cochrane Library (1950-June 2008), 12 published studies met the inclusion criteria. The link between sexual identity and sexual behavior is a complex phenomenon strongly embedded in a very specific context in India. MSM in India are an important risk group for acquiring STIs/HIV and effective culturally sensitive prevention programs should be designed for them. The combined estimate of HIV prevalence in the MSM population in India calculated from 5 included studies was 16.5% (95% confidence intervals: 11% to 22%). The review also identifies the lacunae in existing literature and provides future directions for research in the MSM community in India.

Evolving spectrum and incidence of non-AIDS-defining malignancies

PURPOSE OF REVIEW

Non-AIDS defining cancer (NADC) has emerged as an important cause of morbidity and mortality in the HIV-infected population. Insight into the incidence, spectrum, risk factors, management, and outcome of these cancers has continued to emerge. The recent literature on this topic is reviewed.

RECENT FINDINGS

Several recent studies have explored the shifting spectrum of NADC in both developed and underdeveloped regions of the world. Investigators have shown only a minor difference in the geographic spectrum of NADC. Although several NADC have continued to occur at rates significantly higher than expected, a noticeable decline was observed in other cancers despite antiretroviral therapy. Factors other than HIV and immunosuppression proved to be important in the risk, treatment response, and outcome of these neoplasms. Studies dealing with the management of several NADC were published, including the role of highly active antiretroviral therapy (HAART).

SUMMARY

An increased overall relative risk of developing NADC continues to be reported in the HIV-infected population worldwide. The development of NADC appears to be multifactorial. Although control of HIV viremia has proven to be beneficial, the impact of HAART on NADC incidence rates and survival is not uniform. Further effort is needed to resolve the direct and indirect effects of HIV on NADC in order to guide effective prevention and treatment strategies of these malignancies.

Cancer risk in persons with HIV/AIDS in India: a review and future directions for research

Background

India has a large and evolving HIV epidemic. Little is known about cancer risk in Indian persons with HIV/AIDS (PHA) but risk is thought to be low.

Methods

To describe the state of knowledge about cancer patterns in Indian PHA, we reviewed reports from the international and Indian literature.

Results

As elsewhere, non-Hodgkin lymphomas dominate the profile of recognized cancers, with immunoblastic/large cell diffuse lymphoma being the most common type. Hodgkin lymphoma is proportionally increased, perhaps because survival with AIDS is truncated by fatal infections. In contrast, Kaposi sarcoma is rare, in association with an apparently low prevalence of Kaposi sarcoma-associated herpesvirus. If confirmed, the reasons for the low prevalence need to be understood. Cervical, anal, vulva/vaginal and penile cancers all appear to be increased in PHA, based on limited data. The association may be confounded by sexual behaviors that transmit both HIV and human papillomavirus. Head and neck tumor incidence may also be increased, an important concern since these tumors are among the most common in India. Based on limited evidence, the increase is at buccal/palatal sites, which are associated with tobacco and betel nut chewing rather than human papillomavirus.

Conclusion

With improving care of HIV and better management of infections, especially tuberculosis, the longer survival of PHA in India will likely increase the importance of cancer as a clinical problem in India. With the population's geographic and social diversity, India presents unique research opportunities that can be embedded in programs targeting HIV/AIDS and other public health priorities.