Effect of immunodeficiency, HIV viral load, and antiretroviral

Effect of immunodeficiency, HIV viral load, and antiretroviral therapy on the risk of individual malignancies (FHDH-ANRS CO4): a prospective cohort study.

The relative roles of immunodeficiency, HIV viral load, and combination antiretroviral therapy in the onset of individual cancers have rarely been examined. The authors examined the effect of these factors on the risk of specific cancers in patients infected with HIV-1. They investigated the incidence of both AIDS-defining cancers (Kaposi's sarcoma, non-Hodgkin lymphoma, and cervical cancer) and non-AIDS-defining cancers (Hodgkin's lymphoma, lung cancer, liver cancer, and anal cancer) in 52 278 patients followed up in the French Hospital Database on HIV cohort during 1998-2006 (median follow-up 4.9 years, IQR 2.1-7.9; 255 353 person-years). They tested 78 models with different classifications of immunodeficiency, viral load, and combination antiretroviral therapy with Poisson regression. Current CD4 cell count was the most predictive risk factor for all malignancies apart from anal cancer. Compared with patients with CD4 count greater than 500 cells per muL, rate ratios ranged from 1.9 (95% CI 1.3-2.7) for CD4 counts 350-499 cells per muL to 25.2 (17.1-37.0) for counts less than 50 cells per muL for Kaposi's sarcoma (p<0.0001), p="0.0002)." p="0.07,">The rate ratios of cervical cancer for those receiving combination antiretroviral therapy was 0.5 (0.3-0.9; p=0.03). The risk of anal cancer increased with the time during which the CD4 count was less than 200 cells per muL (1.3 per year, 1.2-1.5; p=0.0001), and viral load was greater than 100 000 copies per mL (1.2 per year, 1.1-1.4, p=0.005). Combination antiretroviral therapy would be most beneficial if it restores or maintains CD4 count above 500 cells per muL, thereby indicating an earlier diagnosis of HIV infection and an earlier treatment initiation. Cancer-specific screening programmes need to be assessed in patients with HIV.

Editors’ note: Patients with HIV have a higher risk than does the general population of both AIDS-defining and non-AIDS-defining cancers. However, since the introduction of antiretroviral treatment, the incidence of AIDS-defining cancers has decreased, whereas that of non-AIDS-defining cancers has increased. Both the size of this French cohort and its length of follow-up allowed investigation of seven specific cancers, finding that the risk of all of them increased with immunodeficiency. Among patients with Kaposi’s sarcoma, men who have sex with men are over-represented. Among patients with liver cancer and lung cancer, injecting drug users are over-represented. Antiretroviral treatment to keep CD4 counts above 500 cells combined with regular cervical-screening programmes for all HIV-positive women and early detection of anal cancer in men could help improve HIV-related cancer outcomes.