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Llibre JM, Revollo B, Aceiton J, Díaz Y, Domingo P, Burgos J, Sorni P, Saumoy M, Knobel H, Navarro M, Leon E, Orti A, Arbonés L, Mera A, Deig E, Sirera G, Miró JM, Casabona J, Martin-Iguacel R. Identifying risk factors for anal cancer in people with HIV in Spain: a multicentre retrospective cohort study nested in the PISCIS cohort. Lancet HIV 2024; 11:e598-e606. [PMID: 39102835 DOI: 10.1016/s2352-3018(24)00174-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 06/16/2024] [Accepted: 06/18/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND People with HIV have a substantially higher risk of anal cancer than the general population. We aimed to identify risk factors associated with the development of anal cancer among people with HIV to implement more effective and targeted screening strategies. METHODS We conducted a multicentre retrospective cohort study in 16 hospitals across Catalonia and the Balearic Islands, Spain, between Jan 1, 1998, and Dec 31, 2022. Treatment-naive people with HIV nested in the PISCIS cohort aged 16 years and older with biopsy-proven squamous cell carcinoma of the anus or anal canal were eligible for inclusion. Data were retrieved from every hospital registry and were centrally validated in the PISCIS cohort and the Public Data Analysis for Health Research and Innovation Program. The primary outcome was the incidence rate (IR) of histologically confirmed anal cancer. We used Poisson regression to examine the association between the following risk factors and incidence of anal cancer: age, mode of HIV transmission, nadir CD4 cell count, and time period of HIV diagnosis. FINDINGS Among 14 238 people with HIV, 107 (0·8%) developed anal cancer, with an overall IR of 72·5 cases per 100 000 person-years (95% CI 59·4-87·6) and median follow-up of 9·5 years (IQR 4·4-15·7). Of these patients with anal cancer, 37 (34·6%) died, of which 24 (64·9%) deaths were related to anal cancer. Incidence was highest among people with HIV with historical nadir CD4 counts of less than 200 cells per μL (IR 105·0 person-years, 95% CI 82·0-132·5) and lowest among those with counts of more than 350 cells per μL (2·9 person-years, 0·1-16·0). Among men who have sex with men (MSM), the IR was 211·5 person-years (95% CI 151·1-211·7) among those with a CD4 count of less than 200 cells per μL, 37·6 person-years (16·2-74·1) among those with a count of 200-350 cells per μL, and 4·8 person-years (0·1-26·9) among those with a count of more than 350 cells per μL. Among people with HIV younger than 30 years, there were no cases of anal cancer among women or men who do not have sex with men, and one case among MSM with a nadir CD4 count of more than 350 cells per μL (IR 4·8 person-years, 95% CI 0·1-26·9). In the multivariable analysis, people with HIV with nadir CD4 counts of more than 350 cells per μL had the lowest risk of developing anal cancer, compared with people with HIV with counts of less than 200 cells per μL (adjusted IR ratio 0·03, 95% CI 0·00-0·25; p=0·0010) or 200-350 cells per μL (0·30, 0·17-0·55; p<0·0001). Compared with people with HIV younger than 30 years, people with HIV aged 60 years and older had an adjusted IR ratio of 27·6 (3·7-206·9; p=0·0010) and people with HIV aged 45-59 years of 21·6 (3·0-156·4; p=0·0020). Compared with individuals diagnosed after 2015, a diagnosis of HIV before 1998 had an adjusted IR ratio of 33·0 (7·9-137·5; p<0·0001). INTERPRETATION A nadir CD4 count threshold below 350 cells per μL, particularly less than 200 cells per μL, has the potential to identify people with HIV at heightened risk of developing anal cancer. Customised screening strategies that prioritise screening for individuals at high risk with this surrogate marker could maximise available resources. External validation of these data with other cohorts is required before screening recommendations can be updated. FUNDING Catalan Health Department, Generalitat de Catalunya.
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Affiliation(s)
- Josep M Llibre
- Infectious Diseases Division, University Hospital Germans Trias, Barcelona, Spain; Fight Infections Foundation, Barcelona, Spain.
| | - Boris Revollo
- Infectious Diseases Division, University Hospital Germans Trias, Barcelona, Spain; Fight Infections Foundation, Barcelona, Spain
| | - Jordi Aceiton
- Centre of Epidemiological Studies of HIV/AIDS and STI of Catalonia, Health Department, Generalitat de Catalunya, Barcelona, Spain
| | - Yesika Díaz
- Centre of Epidemiological Studies of HIV/AIDS and STI of Catalonia, Health Department, Generalitat de Catalunya, Barcelona, Spain
| | - Pere Domingo
- HIV Unit, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Joaquim Burgos
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Patricia Sorni
- Department of Internal Medicine, Son Llàtzer Hospital, Palma de Mallorca, Spain
| | - Maria Saumoy
- HIV and STD Unit, Bellvitge University Hospital, Bellvitge Biomedical Research Institute, Hospitalet de Llobregat, Barcelona, Spain
| | - Hernando Knobel
- Department of Infectious Diseases, Hospital del Mar-Parc de Salut MAR, Barcelona, Spain; Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Infecciosas, Institute of Health Carlos III, Madrid, Spain
| | - Marta Navarro
- Infectious Diseases Department, Parc Taulí Hospital Universitari, Sabadell, Spain
| | - Elena Leon
- Department of Internal Medicine, Hospital Moises Broggi, Sant Joan Despí, Spain
| | - Amat Orti
- Department of Internal Medicine, Verge de la Cinta Hospital, Tortosa, Spain
| | - Laia Arbonés
- Department of Internal Medicine, Consorci Sanitari del Maresme, Mataró, Spain
| | - Arantxa Mera
- Department of Internal Medicine, Hospital de Palamós, Girona, Spain
| | - Elisabet Deig
- Department of Internal Medicine, Hospital General de Granollers, Barcelona, Spain
| | - Guillem Sirera
- Infectious Diseases Division, University Hospital Germans Trias, Barcelona, Spain; Fight Infections Foundation, Barcelona, Spain
| | - Josep M Miró
- Centro de Investigación Biomédica en Red Enfermedades Infecciosas, Institute of Health Carlos III, Madrid, Spain; Infectious Diseases Service, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - Jordi Casabona
- Centre of Epidemiological Studies of HIV/AIDS and STI of Catalonia, Health Department, Generalitat de Catalunya, Barcelona, Spain
| | - Raquel Martin-Iguacel
- Centre of Epidemiological Studies of HIV/AIDS and STI of Catalonia, Health Department, Generalitat de Catalunya, Barcelona, Spain; Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
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Nicolau IA, Moineddin R, Brooks JD, Antoniou T, Gillis JL, Kendall CE, Cooper C, Cotterchio M, Salters K, Smieja M, Kroch AE, Price C, Mohamed A, Burchell AN. Associations of CD4 Cell Count Measures With Infection-Related and Infection-Unrelated Cancer Risk Among People With HIV. J Acquir Immune Defic Syndr 2024; 96:447-456. [PMID: 38985442 DOI: 10.1097/qai.0000000000003452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/09/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND People with HIV are at higher risk of infection-related cancers than the general population, which could be due, in part, to immune dysfunction. Our objective was to examine associations between 4 CD4 count measures as indicators of immune function and infection-related and infection-unrelated cancer risk. SETTING We conducted a cohort study of adults with HIV who were diagnosed with cancer in Ontario, Canada. Incident cancers were identified from January 1, 1997 to December 31, 2020. METHODS We estimated adjusted hazard ratios (aHR) for the associations between CD4 measures (baseline CD4, nadir CD4, time-updated CD4, time-updated CD4:CD8) and cancer incidence rates using competing risk analyses, adjusted for socio-demographic factors, history of hepatitis B or C infection, baseline viral load, smoking, and alcohol use. RESULTS Among 4771 people with HIV, contributing 59,111 person-years of observation, a total of 549 cancers were observed. Low baseline CD4 (<200 cells/µL) (aHR 2.08 [95% CI: 1.38 to 3.13], nadir (<200 cells/µL) (aHR 2.01 [95% CI: 1.49 to 2.71]), low time-updated CD4 (aHR 3.52 [95% CI: 2.36 to 5.24]) and time-updated CD4:CD8 ratio (<0.4) (aHR 2.02 [95% CI: 1.08 to 3.79]) were associated with an increased rate of infection-related cancer. No associations were observed for infection-unrelated cancers. CONCLUSIONS Low CD4 counts and indices were associated with increased rates of infection-related cancers among people with HIV, irrespective of the CD4 measure used. Early diagnosis and linkage to care and high antiretroviral therapy uptake may lead to improved immune function and could add to cancer prevention strategies such as screening and vaccine uptake.
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Affiliation(s)
- Ioana A Nicolau
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Jennifer D Brooks
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tony Antoniou
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | | | - Claire E Kendall
- ICES, Toronto, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Curtis Cooper
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michelle Cotterchio
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Kate Salters
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | | | - Abigail E Kroch
- Ontario HIV Treatment Network, Toronto, Ontario, Canada; and
| | - Colleen Price
- Canadian HIV/AIDS and Chronic Pain Society, Ottawa, Ontario, Canada
| | - Anthony Mohamed
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Ann N Burchell
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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Hewitt A, Kawak S, Yang Q, Stafford LC, Bailey HH, Striker R, Hayden DM, Sanger CB. Risk of developing high-grade squamous intraepithelial lesions or anal cancer after anal condylomata treatment in people living with HIV. Colorectal Dis 2024. [PMID: 39099077 DOI: 10.1111/codi.17099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 05/23/2024] [Accepted: 06/25/2024] [Indexed: 08/06/2024]
Abstract
AIM To assess the risk and natural history of developing advanced anal disease after diagnosis of anal condyloma in people living with HIV (PLWH). METHODS This was a single-centre retrospective cohort study of PLWH and anal condyloma from 2001 to 2021. Patients who developed advanced anal disease (AAD; anal high-grade squamous intraepithelial lesions and/or anal cancer) were compared to those who did not progress (non-AAD). We assessed the potential association between AAD and condyloma location, recurrence, and treatment modality. AAD-free survival was calculated utilizing Kaplan-Meier methods. RESULTS A total of 118 PLWH and anal condyloma were included. Mean overall follow-up time was 9.3 years. A total of 31% of patients developed AAD (n = 37). Average time to AAD from condyloma diagnosis was 5.6 years. On multivariate analysis, risk for AAD development was associated with perianal location of condyloma (OR 4.39, p = 0.038) and increased time from initial condyloma diagnosis (OR 1.12, p = 0.008). Higher CD4/CD8 ratios were associated with lower risk of AAD (OR 0.15, p = 0.029). Condyloma recurrence and treatment type were not associated with development of AAD. AAD-free survival was longer in those with intra-anal only condyloma versus those with either perianal disease alone or combined intra-anal/perianal disease (mean survival times: 22.8 vs. 8.7 vs. 10.7 years, p = 0.017). CONCLUSION Our study demonstrates the need for careful, long-term follow-up of PLWH and condyloma, particularly in the setting of perianal disease and low CD4/CD8 ratio. Risk of anal disease progression is present even in the setting of condyloma regression following treatment.
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Affiliation(s)
- Austin Hewitt
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Samer Kawak
- Department of Colon and Rectal Surgery, Riverview Health, Noblesville, Indiana, USA
| | - Qiuyu Yang
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Linda Cherney Stafford
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Howard H Bailey
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- University of Wisconsin Carbone Cancer Centre, Madison, Wisconsin, USA
| | - Robert Striker
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Dana M Hayden
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Cristina B Sanger
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Surgery, William S. Middleton Memorial Veteran's Hospital, Madison, Wisconsin, USA
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Stem J, Hewitt AJ, Yang Q, Sanger CB. Commonly Drawn Immunologic and Inflammatory Markers as Risk Predictors for Anal Cancer in Veterans Living With HIV. J Low Genit Tract Dis 2024; 28:300-304. [PMID: 38661377 PMCID: PMC11213675 DOI: 10.1097/lgt.0000000000000811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVES This study aimed to determine if immune inflammatory markers (neutrophil lymphocyte ratio [NLR], platelet lymphocyte ratio [PLR], and prognostic nutritional index [PNI]) correlate with anal cancer risk in people living with HIV and to compare these markers with the CD4/CD8 ratio. MATERIALS AND METHODS This is a regional retrospective cohort study of veterans living with HIV who were screened for or diagnosed with anal neoplasia or cancer from 2001 to 2019. The NLR, PLR, PNI, and CD4/CD8 ratio within 1 year of anal pathology results were computed. Patients with anal cancer were compared to patients without anal cancer. Regression modeling was used to estimate the odds of developing anal cancer. RESULTS Three hundred thirty-four patients were included (37 with anal cancer, 297 without anal cancer). In patients with anal cancer, NLR and PLR were higher (2.17 vs 1.69, p = .04; 140 vs 110, p = .02, respectively), while PNI and CD4/CD8 ratio were lower (44.65 vs 50.01, p < .001; 0.35 vs 0.80, p < .001, respectively). On multivariate logistic regression modeling, only PNI (odds ratio, 0.90; p = .001) and CD4/CD8 ratio (odds ratio, 0.05; p < .001) were associated with increased anal cancer risk. CONCLUSIONS Although NLR and PLR independently correlate with anal cancer risk, when controlling for other risk predictors, only PNI and CD4/CD8 ratio were statistically significant biomarkers for anal cancer. The CD4/CD8 ratio is the strongest immune inflammatory marker that predicts risk of anal cancer among veterans living with HIV.
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Affiliation(s)
- Jonathan Stem
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Austin J. Hewitt
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Qiuyu Yang
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Cristina B. Sanger
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Surgery, William S. Middleton Memorial Veteran’s Hospital, Madison, WI, USA
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Gergen M, Hewitt A, Sanger CB, Striker R. Monitoring immune recovery on HIV therapy: critical, helpful, or waste of money in the current era? AIDS 2024; 38:937-943. [PMID: 38310348 PMCID: PMC11064897 DOI: 10.1097/qad.0000000000003850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 02/05/2024]
Affiliation(s)
| | | | - Cristina B. Sanger
- Department of Surgery
- Department of Surgery, W. S. Middleton Memorial Veterans’ Hospital, Madison, WI, USA
| | - Rob Striker
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health
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Schuettfort G, Röther C, Berger A, Fokas E, Fraunholz I, Groh A, Haberl A, Khaykin P, Martin D, Rödel C, Vehreschild M, Stephan C. Differences in the Course of CD4 and CD8 Cells After Chemoradiotherapy in People Living with HIV with Anal Cancer. AIDS Res Hum Retroviruses 2024; 40:198-203. [PMID: 37756364 DOI: 10.1089/aid.2023.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Abstract
Incidence of anal carcinoma (AC) in people living with HIV (PLWH) is increased compared to the general population. Adverse effects of chemoradiotherapy (CRT) on the immune system are associated with a significant detrimental prognosis on overall survival in patients receiving CRT for solid tumors. The aim of this study was to evaluate immunological factors, in particular the differences in recovery of CD4+ and CD8+ cell counts before and after CRT for AC in PLWH. Retrospective single-center chart review extraction to analyze immunological data collected from PLWH with AC; descriptive statistics were used. Thirty-six PLWH with histologically proven AC were included in the analysis. Absolute CD4 cell count 60 months after CRT was 67.2% of the value at the beginning of CRT, whereas the CD8 cell count reached 82.3%. These differences were statistically significant (p = .048), whereas CD4/CD8-ratio remained stable. The findings of the presented study regarding CD4+ and CD8+ cell recovery after CRT are congruent with results from prior studies in non-HIV infected patients. Although not reaching the level of prior CRT T cell numbers, the ability to generate CD8+ cells seems to be better recovered, while CD4+ regeneration is more impaired. These observations are best explained by faster recovery of CD8+ cells via thymic-independent pathways, which are not available for regeneration of CD4+ cells. Further studies with larger numbers of patients are required to analyze the specific CD4+ and CD8+ cell subsets.
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Affiliation(s)
- Gundolf Schuettfort
- Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Annemarie Berger
- Department of Virology and University Hospital Frankfurt, Frankfurt, Germany
| | - Emmanouil Fokas
- Department of Radiotherapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Ingeborg Fraunholz
- Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | - Ana Groh
- Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | - Annette Haberl
- Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Daniel Martin
- Department of Radiotherapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Claus Rödel
- Department of Radiotherapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Maria Vehreschild
- Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | - Christoph Stephan
- Department of Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
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Pérez-González A, Rodríguez-Rivero S, Fernández-Veiga P, Flores E, Poveda E, González-Carreró J, Pérez-Castro S, Labajo-Leal L, Miralles C, Ocampo A. Anal Dysplasia Screening in People Living with HIV: Long-Term Follow-Up in a Large Cohort from Northwest Spain. AIDS Patient Care STDS 2024; 38:5-13. [PMID: 38117576 PMCID: PMC10794828 DOI: 10.1089/apc.2023.0231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
Anal squamous cell carcinoma (SCC) is not a common disease in the general population, although its incidence is higher in people living with human immunodeficiency virus (PLWH). Anal SCC is caused by human papillomavirus (HPV) infection and arises from premalignant lesions termed squamous intraepithelial lesions (SILs). SIL surveillance programs are based on the early detection and treatment of SILs, especially those with a higher risk of transforming into cancer. An anal surveillance program has been under development in our institution since 2011. In this context, we performed a retrospective cohort study at the anal dysplasia unit of Álvaro-Cunqueiro Hospital (Spain). Epidemiological and clinical data were gathered from our Infectious Diseases Sample Collection (an open sample cohort including PLWH) from January 2011 to January 2022. A total of 493 PLWH were considered, 122 (24.7%) of whom were diagnosed with anal dysplasia at baseline, including 2 cases of anal SCC. Briefly, most of individuals were young men (median age, 38 years old) born in Spain (76%), whose vaccination rate before their inclusion in the program was scarce (<3%). Throughout the study period, 81 (16.4%) cases were diagnosed with high-grade squamous-intraepithelial lesions (HSILs) and 3 with anal SCC. At the baseline, severe immunosuppression (i.e., nadir CD4+ lymphocyte count below 200 cell/μL), and prior diagnosis of condyloma acuminata were more frequent within the group with SILs. Conversely, the baseline CD4+ lymphocyte count was similar among both groups. HPV-16 was related to a higher risk of HSILs (odds ratio: 2.76). At the end of the follow-up, 385 PLWH had been retained in care; one patient had died of anal cancer. Anal dysplasia was common (25% of cases), especially among patients infected by HPV-16, diagnosed with condyloma acuminata, and who were severely immunosuppressed. HPV-16 was the main risk factor for the presentation of HSILs.
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Affiliation(s)
- Alexandre Pérez-González
- Virology and Pathogenesis Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
- Infectious Diseases Unit, Department of Internal Medicine, Álvaro Cunqueiro Hospital, Vigo, Spain
| | | | - Pilar Fernández-Veiga
- Anal Dysplasia Unit, General Surgery Department, Álvaro Cunqueiro Hospital, Vigo, Spain
| | - Erene Flores
- Anal Dysplasia Unit, General Surgery Department, Álvaro Cunqueiro Hospital, Vigo, Spain
| | - Eva Poveda
- Virology and Pathogenesis Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | | | - Sonia Pérez-Castro
- Microbiology and Infectology Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
- Microbiology Department, Complexo Hospitalario Universitario de Vigo (CHUVI), Sergas, Vigo, Spain
| | - Laura Labajo-Leal
- Infectious Diseases Unit, Department of Internal Medicine, Álvaro Cunqueiro Hospital, Vigo, Spain
| | - Celia Miralles
- Infectious Diseases Unit, Department of Internal Medicine, Álvaro Cunqueiro Hospital, Vigo, Spain
| | - Antonio Ocampo
- Infectious Diseases Unit, Department of Internal Medicine, Álvaro Cunqueiro Hospital, Vigo, Spain
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Sanger CB, Kalbfell E, Cherney-Stafford L, Striker R, Alagoz E. A Qualitative Study of Barriers to Anal Cancer Screenings in US Veterans Living with HIV. AIDS Patient Care STDS 2023; 37:436-446. [PMID: 37713286 DOI: 10.1089/apc.2023.0144] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
People living with human immunodeficiency virus (HIV) are at high risk for anal cancer. Anal cancer screenings are recommended annually for US veterans with HIV. Screenings can identify treatable precursor lesions and prevent cancer development. In a previous study, we found screening rate to be only 15%. Semistructured interviews were conducted with Veterans Affairs (VA) providers who treat veterans living with HIV. Participants described their experiences with anal cancer screenings. Researchers developed a codebook based on Theoretical Domains Framework (TDF) and coded data using thematic analysis to identify barriers to anal cancer screenings. Twenty-three interviews were conducted with VA providers representing 10 regions. Barriers identified corresponded with five targetable TDF domains: Knowledge, Skills, Environmental Context/Resources, Professional Roles/Identities, and Social Influence. Many providers lacked knowledge of screening protocols. Knowledgeable providers often lacked needed resources, including swabs, clinic space, reliable pathology, access to high-resolution anoscopy, or leadership support to implement a screening program. Providers mentioned competing priorities in the care of veterans with HIV infection and lack of skilled/trained personnel to perform the tests. It was often unclear which provider specialty should "own" screening responsibilities. Additional factors included patient discomfort with screening exams. Anal cancer screening protocols are recommended but not widely adopted in VA. There is a critical need to address barriers to anal cancer screenings in veterans. The TDF domains identified align with five intervention domains to target, including education, training, resource/environment, delineation of provider roles, and improved counseling efforts. Targeting these barriers may help improve the uptake of anal cancer screenings within VA.
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Affiliation(s)
- Cristina B Sanger
- Division of Colon and Rectal Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Surgery, W. S. Middleton Memorial Veterans' Hospital, Madison, Wisconsin, USA
- Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Elle Kalbfell
- Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Linda Cherney-Stafford
- Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Rob Striker
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Esra Alagoz
- Department of Surgery, Wisconsin Surgical Outcomes Research Program (WiSOR), School of Medicine and Public Health, Madison, Wisconsin, USA
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Sanger CB, Striker R. ASO Author Reflections: Using Objective Markers to Tailor Frequency of Anal Dysplasia Treatments in People Living with HIV. Ann Surg Oncol 2023; 30:4744-4745. [PMID: 36881279 DOI: 10.1245/s10434-023-13215-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 03/08/2023]
Affiliation(s)
- Cristina B Sanger
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave., Madison, WI, 53792, USA.
- Department of Surgery, W. S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
| | - Rob Striker
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, 600 Highland Ave., Madison, WI, 53792, USA
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Karim A, Freeman MJ, Yang Q, Leverson G, Cherney-Stafford L, Striker R, Sanger CB. Duration of Time CD4/CD8 Ratio is Below 0.5 is Associated with Progression to Anal Cancer in Patients with HIV and High-Grade Dysplasia. Ann Surg Oncol 2023; 30:4737-4743. [PMID: 36869915 DOI: 10.1245/s10434-023-13213-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND A CD4/CD8 ratio < 0.5 is associated with increased risk of advanced anal disease (AAD) but it is unknown if duration below 0.5 matters. The purpose of this study was to determine if duration of a CD4/CD8 ratio < 0.5 is associated with increased risk of invasive anal cancer (IC) in people living with HIV and high-grade dysplasia (HSIL). METHODS This single institution, retrospective study used the University of Wisconsin Hospital and Clinics Anal Dysplasia and Anal Cancer Database. Patients with IC versus HSIL alone were compared. Independent variables were mean and percentage of time the CD4/CD8 ratio was < 0.5. Multivariate logistic regression was performed to estimate the adjusted odds of anal cancer. RESULTS We identified 107 patients with HIV infection and AAD (87 with HSIL, 20 with IC). A history of smoking was significantly associated with the development of IC (95% in patients with IC vs. 64% in patients with HSIL; p = 0.015). Mean time the CD4/CD8 ratio was < 0.5 was significantly longer in patients with IC compared with patients with HSIL (7.7 years vs. 3.8 years; p = 0.002). Similarly, the mean percentage of time the CD4/CD8 ratio was < 0.5 was higher in those with IC versus those with HSIL (80% vs. 55%; p = 0.009). On multivariate analysis, duration CD4/CD8 ratio was < 0.5 was associated with increased odds of developing IC (odds ratio 1.25, 95% confidence interval 1.02-1.53; p = 0.034). CONCLUSIONS In this retrospective, single-institution study of a cohort of people living with HIV and HSIL, increasing duration the CD4/CD8 ratio was < 0.5 was associated with increased odds of developing IC. Monitoring the number of years the CD4/CD8 ratio is < 0.5 could inform decision making in patients with HIV infection and HSIL.
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Affiliation(s)
- Aos Karim
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, USA
| | - Matthew J Freeman
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, USA
| | - Qiuyu Yang
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, USA
| | - Linda Cherney-Stafford
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, USA
| | - Rob Striker
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Cristina B Sanger
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, USA.
- Department of Surgery, W.S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
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Pérez-González A, Cachay E, Ocampo A, Poveda E. Update on the Epidemiological Features and Clinical Implications of Human Papillomavirus Infection (HPV) and Human Immunodeficiency Virus (HIV) Coinfection. Microorganisms 2022; 10:1047. [PMID: 35630489 PMCID: PMC9147826 DOI: 10.3390/microorganisms10051047] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 12/01/2022] Open
Abstract
Human papillomavirus (HPV) infection is the most common sexually transmitted infection (STI) worldwide. Although most HPV infections will spontaneously resolve, a considerable proportion of them will persist, increasing the risk of anogenital dysplasia, especially within certain populations, such as patients infected with human immunodeficiency virus (HIV). Furthermore, high-risk oncogenic HPV types (HR-HPV) are the main cause of cervix and other anogenital cancers, such as cancer of the vagina, vulva, penis, or anus. HIV and HPV coinfection is common among people living with HIV (PLWH) but disproportionally affects men who have sex with men (MSM) for whom the rate of persistent HPV infection and reinfection is noteworthy. The molecular interactions between HIV and HPV, as well as the interplay between both viruses and the immune system, are increasingly being understood. The immune dysfunction induced by HIV infection impairs the rate of HPV clearance and increases its oncogenic risk. Despite the availability of effective antiretroviral therapy (ART), the incidence of several HPV-related cancers is higher in PLWH, and the burden of persistent HPV-related disease has become a significant concern in an aging HIV population. Several public health strategies have been developed to reduce the transmission of HIV and HPV and mitigate the consequences of this type of coinfection. Universal HPV vaccination is the most effective preventive tool to reduce the incidence of HPV disease. In addition, screening programs for HPV-related cervical and vulvovaginal diseases in women are well-recognized strategies to prevent cervical cancer. Similarly, anal dysplasia screening programs are being implemented worldwide for the prevention of anal cancer among PLWH. Herein, the main epidemiological features and clinical implications of HIV and HPV coinfection are reviewed, focusing mainly on the relationship between HIV immune status and HPV-related diseases and the current strategies used to reduce the burden of HPV-related disease.
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Affiliation(s)
- Alexandre Pérez-González
- Group of Virology and Pathogenesis, Galicia Sur Health Research Institute (IIS Galicia Sur), 36312 Vigo, Spain;
- Infectious Disease Unit, Internal Medicine Department, Hospital Álvaro Cunqueiro, 36312 Vigo, Spain;
| | - Edward Cachay
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California at San Diego, San Diego, CA 92093, USA;
| | - Antonio Ocampo
- Infectious Disease Unit, Internal Medicine Department, Hospital Álvaro Cunqueiro, 36312 Vigo, Spain;
| | - Eva Poveda
- Group of Virology and Pathogenesis, Galicia Sur Health Research Institute (IIS Galicia Sur), 36312 Vigo, Spain;
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12
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Mechanisms of immune aging in HIV. Clin Sci (Lond) 2022; 136:61-80. [PMID: 34985109 DOI: 10.1042/cs20210344] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 12/11/2022]
Abstract
Massive CD4+ T-cell depletion as well as sustained immune activation and inflammation are hallmarks of Human Immunodeficiency Virus (HIV)-1 infection. In recent years, an emerging concept draws an intriguing parallel between HIV-1 infection and aging. Indeed, many of the alterations that affect innate and adaptive immune subsets in HIV-infected individuals are reminiscent of the process of immune aging, characteristic of old age. These changes, of which the presumed cause is the systemic immune activation established in patients, likely participate in the immuno-incompetence described with HIV progression. With the success of antiretroviral therapy (ART), HIV-seropositive patients can now live for many years despite chronic viral infection. However, acquired immunodeficiency syndrome (AIDS)-related opportunistic infections have given way to chronic diseases as the leading cause of death since HIV infection. Therefore, the comparison between HIV-1 infected patients and uninfected elderly individuals goes beyond the sole onset of immunosenescence and extends to the deterioration of several physiological functions related to inflammation and systemic aging. In light of this observation, it is interesting to understand the precise link between immune activation and aging in HIV-1 infection to figure out how to best care for people living with HIV (PLWH).
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