The impact of highly active antiretroviral therapy on the incidence and outcomes of AIDS-defining cancers in Southern Alberta

The Effect of MSM and CD4+ Count on the Development of Cancer AIDS (AIDS-defining Cancer) and Non-cancer AIDS in the HAART Era

BACKGROUND

The HIV epidemic is increasing among Men who have Sex with Men (MSM) and the risk for AIDS defining cancer (ADC) is higher among them.

OBJECTIVE

To examine the effect of MSM and CD4+ count on time to cancer AIDS (ADC) and noncancer AIDS in competing risks setting in the HAART era.

METHOD

Using Ontario HIV Treatment Network Cohort Study data, HIV-positive adults diagnosed between January 1997 and October 2012 having baseline CD4+ counts ≤ 500 cells/mm3 were evaluated. Two survival outcomes, cancer AIDS and non-cancer AIDS, were treated as competing risks. Kaplan-Meier analysis, Cox cause-specific hazards (CSH) model and joint modeling of longitudinal and survival outcomes were used.

RESULTS

Among the 822 participants, 657 (79.9%) were males; 686 (83.5%) received anti-retroviral (ARV) ever. Regarding risk category, the majority (58.5%) were men who have Sex with men (MSM). Mean age was 37.4 years (SD = 10.3). In the multivariate Cox CSH models, MSM were not associated with cancer AIDS but with non-cancer AIDS [HR = 2.92; P = 0.055, HR = 0.54; P = 0.0009, respectively]. However, in joint models of longitudinal and survival outcomes, MSM were associated with cancer AIDS but not with non-cancer AIDS [HR = 3.86; P = 0.013, HR = 0.73; P = 0.10]. CD4+ count, age, ARV ever were associated with both events in the joint models.

CONCLUSION

This study demonstrates the importance of considering competing risks, and timedependent biomarker in the survival model. MSM have higher hazard for cancer AIDS. CD4+ count is associated with both survival outcomes.

KS-Detect - Validation of Solar Thermal PCR for the Diagnosis of Kaposi's Sarcoma Using Pseudo-Biopsy Samples

Resource-limited settings present unique engineering challenges for medical diagnostics. Diagnosis is often needed for those unable to reach central healthcare systems, making portability and independence from traditional energy infrastructure essential device parameters. In 2014, our group presented a microfluidic device that performed a solar-powered variant of the polymerase chain reaction, which we called solar thermal PCR. In this work, we expand on our previous effort by presenting an integrated, portable, solar thermal PCR system targeted towards the diagnosis of Kaposi’s sarcoma. We call this system KS-Detect, and we now report the system’s performance as a diagnostic tool using pseudo-biopsy samples made from varying concentrations of human lymphoma cell lines positive for the KS herpesvirus (KSHV). KS-Detect achieved 83% sensitivity and 70% specificity at high (≥10%) KSHV+ cell concentrations when diagnosing pseudo-biopsy samples by smartphone image. Using histology, we confirm that our prepared pseudo-biopsies contain similar KSHV+ cell concentrations as human biopsies positive for KS. Through our testing of samples derived from human cell lines, we validate KS-Detect as a viable, portable KS diagnostic tool, and we identify critical engineering considerations for future solar-thermal PCR devices.

Assessing the impact of HAART on the incidence of defining and non-defining AIDS cancers among patients with HIV/AIDS: a systematic review

After highly active antiretroviral therapy (HAART) became widespread, several studies demonstrated changes in the incidence of defining and non-defining AIDS cancers among HIV/AIDS patients. We conducted a systematic review of observational studies evaluating the incidence of malignancies before and after the introduction of HAART in people with HIV/AIDS. Eligible studies were searched up to December 2012 in the following databases: Pubmed, Embase, Scielo, Cancerlit and Google Scholar. In this study, we determined the cancer risk ratio by comparing the pre- and post-HAART eras. Twenty-one relevant articles were found, involving more than 600,000 people with HIV/AIDS and 10,891 new cases of cancers. The risk for the development of an AIDS-defining cancer decreased after the introduction of HAART: Kaposi's sarcoma (RR=0.30, 95% CI: 0.28-0.33) and non-Hodgkin's lymphoma (RR=0.52, 95% CI: 0.48-0.56), in contrast to invasive cervical cancer (RR=1.46, 95% CI: 1.09-1.94). Among the non-AIDS-defining cancers, the overall risk increased after the introduction of HAART (RR=2.00, 95% CI: 1.79-2.23). The incidence of AIDS-defining cancers decreased and the incidence of non-AIDS-defining cancers increased after the early use of HAART, probably due to better control of viral replication, increased immunity and increased survival provided by new drugs.

Hepatocellular cancer in HIV-infected individuals: tomorrow’s problem?

A number of cancers occur with increased frequency in individuals with HIV infection. There is a debate as to whether or not hepatocellular cancer is one of these tumors. This article reviews the current data regarding incidence etiology, treatment and outcome for HIV-related hepatocellular cancer. It also attempts to predict future areas of importance in the management of these patients in the era of highly active antiretroviral therapy.

Higher levels of neutralizing antibodies against KSHV in KS patients compared to asymptomatic individuals from Zambia

Kaposi sarcoma-associated herpesvirus (KSHV) is the etiologic agent for Kaposi Sarcoma (KS), the most common cancer diagnosed in HIV- infected patients. The role of neutralizing antibodies in KS pathogenesis and in KSHV infected individuals is not clearly understood. The goal of this study was to investigate and compare the prevalence and titers of neutralizing antibodies in plasma samples from KS patients and KSHV infected asymptomatic individuals from Zambia, a KS endemic region in sub-Saharan Africa. Plasma samples (N = 267) consisting of KS patients (group 1) and asymptomatic individuals (group 2) were collected from Lusaka, Zambia. A flow cytometry based quantitative neutralization assay utilizing recombinant KSHV expressing GFP was used to detect KSHV neutralizing antibodies. Our results show that the overall prevalence of neutralizing antibodies in KS patients (group 1) was 66.7% which was significantly higher than the prevalence of 6.5% present in KSHV infected asymptomatic individuals (group 2). Total antibody titers as well as neutralizing antibodies titers were found to be significantly higher among KS patients. It is likely that higher neutralizing antibodies prevalence and titers in KS patients result from higher levels of antigenic stimulation over time. This study is first to compare prevalence and titers of neutralizing antibodies in participants with and without disease from a KSHV endemic region.

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.

Impact of antiretroviral therapy on the incidence of Kaposi's sarcoma in resource-rich and resource-limited settings

PURPOSE OF REVIEW

Given the recent availability of antiretroviral therapy (ART) in resource-limited settings and the significant burden exacted by Kaposi's sarcoma in these areas, we reviewed data regarding the impact of ART on Kaposi's sarcoma incidence. We summarized the sizeable literature in resource-rich settings as well as emerging data from resource-limited regions. Importantly, we delineated ways impact can be defined, including individual patient-level effectiveness; population-level effectiveness; change in population-level incidence; and residual risk of Kaposi's sarcoma.

RECENT FINDINGS

In resource-rich settings, there are now ample data demonstrating beneficial individual patient-level and population-level effects of ART on Kaposi's sarcoma incidence. There is, however, considerable variability between studies and important methodologic shortcomings. Data from resource-limited settings are much more limited; although they preliminarily indicate individual patient-level effectiveness, they do not yet provide insight on population-level effects.

SUMMARY

ART has had a substantial impact on Kaposi's sarcoma incidence in resource-rich settings, but more attention is needed on validly quantifying this effect in order to determine whether additional interventions are needed. Emerging data from resource-limited regions also suggest beneficial impact of ART on Kaposi's sarcoma incidence, but - given the scope of Kaposi's sarcoma in these settings - more data are needed to understand the breadth and magnitude of the effect.

AIDS-associated Kaposi's sarcoma is linked to advanced disease and high mortality in a primary care HIV programme in South Africa

BACKGROUND

AIDS-associated Kaposi's sarcoma is an important, life-threatening opportunistic infection among people living with HIV/AIDS in resource-limited settings. In western countries, the introduction of combination antiretroviral therapy (cART) and new chemotherapeutic agents has resulted in decreased incidence and improved prognosis of AIDS-associated Kaposi's sarcoma. In African cohorts, however, mortality remains high. In this study, we describe disease characteristics and risk factors for mortality in a public sector HIV programme in South Africa.

METHODS

We analysed data from an observational cohort study of HIV-infected adults with AIDS-associated Kaposi's sarcoma, enrolled between May 2001 and January 2007 in three primary care clinics. Paper records from primary care and tertiary hospital oncology clinics were reviewed to determine the site of Kaposi's sarcoma lesions, immune reconstitution inflammatory syndrome stage, and treatment. Baseline characteristics, cART use and survival outcomes were extracted from an electronic database maintained for routine monitoring and evaluation. Cox regression was used to model associations with mortality.

RESULTS

Of 6292 patients, 215 (3.4%) had AIDS-associated Kaposi's sarcoma. Lesions were most commonly oral (65%) and on the lower extremities (56%). One quarter of patients did not receive cART. The mortality and lost-to-follow-up rates were, respectively, 25 (95% CI 19-32) and eight (95% CI 5-13) per 100 person years for patients who received cART, and 70 (95% CI 42-117) and 119 (80-176) per 100 person years for patients who did not receive cART. Advanced T stage (adjusted HR, AHR = 5.3, p < 0.001), advanced S stage (AHR = 5.1, p = 0.008), and absence of chemotherapy (AHR = 2.4, p = 0.012) were associated with mortality. Patients with AIDS-associated Kaposi's sarcoma presented with advanced disease and high rates of mortality and loss to follow up. Risk factors for mortality included advanced Kaposi's sarcoma disease and lack of chemotherapy use. Contributing factors to the high mortality for patients with AIDS-associated Kaposi's sarcoma likely included late diagnosis of HIV disease, late accessibility to cART, and sub-optimal treatment of advanced Kaposi's sarcoma.

CONCLUSIONS

These findings confirm the importance of early access to both cART and chemotherapy for patients with AIDS-associated Kaposi's sarcoma. Early diagnosis and improved treatment protocols in resource-poor settings are essential.

[Changes to the prevalence of cervical squamous intraepithelial lesions and risk factors among HIV/AIDS patients attended at a specialized service in southern Brazil from 1995 to 1999 and 2006 to 2007]

The aim of this work was to study changes to the prevalence of cervical squamous intraepithelial lesions (CSIL) among HIV1-positive women following the introduction of highly active antiretroviral therapy (HAART), and to evaluate changes to the prevalence of risk factors for CSIL. Fifty patients were studied in 1995-1999 and 120 patients in 2006-2007. Demographic, behavioral and laboratorial data were collected. The prevalences of CSIL and other risk factors were calculated for the two periods. The prevalence of CSIL was 66% in the first period and 43% in the second period (p = 0.007). The mean CD4 in 1995-1999 was 275.71 (SD 283.23) and in 2006-2007 it was 463.32 (SD 231.90; p=0.001). There were significant changes to the factors of age, skin color, marital status and smoking between the two periods. The decrease in the prevalence of CSIL may be related to the use of the HAART strategy and to changes to the risk factors for CSIL over time.

Comparison of perianal diseases in HIV-positive patients during periods before and after protease inhibitors use: what changed in the 21st century

PURPOSE

Highly active antiretroviral therapy has enabled better control over HIV infection. Thus, the immunologic status of such patients has been improving and we believe that changes in their perianal diseases also have been occurring. This study was designed to compare anorectal disease incidence among HIV-positive patients attended in two eras: prehighly active antiretroviral therapy and highly active antiretroviral therapy.

METHODS

We examined 5,660 HIV-positive patients with anorectal diseases, divided into two groups: 1,860 treated during 1989 to 1995 (Group 1), and 3,800 during 1996 to 2005 (Group 2).

RESULTS

In Group 1, the most common diseases were condylomas (24.7 percent), ulcers (21.8 percent), and anal fistulas (19.7 percent). Tumors occurred in 2.5 percent, with Kaposi's sarcoma in 51.1 percent, and squamous-cell carcinoma in 27.6 percent. In Group 2, the most common anorectal lesions were condylomas (75.6 percent), ulcers (17 percent), and fistulas (12.1 percent). The tumor incidence was 1.8 percent, with squamous-cell carcinoma in 59.4 percent and Kaposi's sarcoma in 23.2 percent. Changes in incidence were statistically significant for the increase in condylomas and fissures, and for the decrease in ulcers, fistulas, and Kaposi's sarcoma among Group 2 patients.

CONCLUSION

Anorectal disease incidences have changed in the highly active anti-retroviral therapy era.

Effect of HAART on incident cancer and noncancer AIDS events among male HIV seroconverters

OBJECTIVE

To explore the impact of highly active antiretroviral therapy (HAART) on the prevention of AIDS-defining cancers relative to other AIDS-defining events.

DESIGN

Prospective cohort study using 2,121 HIV+ male seroconverters (median age: 28 years, 51% white/non-Hispanic) in the Tri-Service AIDS Clinical Consortium (n = 1694) and the Multicenter AIDS Cohort Study (n = 427).

METHODS

Poisson regression models, with calendar periods to represent antiretroviral therapy, were extended to analyze first incident AIDS-defining cancers and other first AIDS-defining events as competing risks.

RESULTS

Eighty-one AIDS-defining cancers (64 Kaposi sarcomas; 17 non-Hodgkin lymphomas) and 343 other AIDS events occurred during 14,483 person-years in 1990-2006. The rate ratio of AIDS-defining cancers during the HAART calendar period was 0.26 (95% confidence limits: 0.15, 0.46) and of other AIDS-defining events was 0.28 (95% confidence limits: 0.21, 0.36) compared with the monotherapy/combination therapy calendar period, adjusting for age, infection duration, race, and cohort. The association of HAART with decreased AIDS incidence seemed to be equal (interaction ratio = 0.95 (95% confidence limits: 0.51, 1.74) for AIDS-defining cancers and other AIDS-defining events.

CONCLUSIONS

In human immunodeficiency virus-infected men, HAART seems equally protective against first AIDS-defining cancers and other first AIDS-defining events.

The oncology impact of highly active antiretroviral therapy

OBJECTIVE

To examine the impact of using highly active antiretroviral therapy (HAART) in a human immunodeficiency virus (HIV) infected population on the chemotherapy related costs of treating acquired immunodeficiency (AIDS)-related cancers.

METHODS

We used the Southern Alberta Clinic (SAC) database to define the incidence and prevalence of AIDS-related cancers in a geographically defined HIV population in both the pre- HAART and HAART eras, and subsequently, the Alberta Cancer Board Pharmacy database to determine the chemotherapy associated costs of the cancer treatment.

RESULTS

During both eras, 60% of AIDS-related cancer patients received chemotherapy. The absolute number of patients treated in the pre-HAART era was 70, but during the HAART era, due to the decreased incidence of these cancers, only 13 patients received chemotherapy. The number of distinct regimens used for AIDS cancer treatment standardised, and decreased from 29 to six between eras. The average per patient cost of chemotherapy in the pre-HAART era was $6111, while in the HAART era it rose to $8817. However, the cost avoidance in chemotherapy costs, due to HAART use in the 'at risk' population, averaged $123 439/year or $471 per 'at risk' patient.

CONCLUSION

The introduction of HAART has dramatically reduced the amount spent on chemotherapy due to a decreased incidence of AIDSrelated cancers, even though the individual patient treatments have become more effective and expensive.