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Both AIDS-defining and non-AIDS-defining cancers are more common in patients with HIV aged less than 65, with further disparities based on race and sex.
“AIDS-defining cancers have been closely linked to HIV infection since the beginning of the epidemic, but we have seen declines in AIDS-defining cancers since effective HIV treatment became widely available,” Jacqueline E. Rudolph, PhD, notes. “Additionally, because people with HIV are living longer, we have seen an increase in non-AIDS-defining cancers. Prior research has shown that there are differences between people in the US with and without HIV regarding the incidence of common cancers, like lung, breast, and prostate, and cancers that have been linked to other pathogens, like anal, liver, and head and neck.”
However, official guidance on how cancer should be managed for aging people with HIV has only recently become available, Dr. Rudolph says. Further, many gaps remain in understanding why the incidence of non-AIDS-defining cancers differs among people with HIV.
For a study published in JAIDS, the researchers used data from Medicaid to examine site-specific cancers, non-AIDS-defining cancers, AIDS-defining cancers, and all-cause mortality by HIV status at baseline. “We wanted to establish whether the reported differences in cancer incidence remained among patients receiving Medicaid, which offers a large yet understudied population of low-income people with HIV,” she says.
PW spoke with Dr. Rudolph to learn more.
PW: What results from your study are important to emphasize?
Dr. Rudolph: First, we want to make sure clinicians are aware of the growing burden of cancers that have not been traditionally associated with HIV. Second, it may be relevant to tailor recommendations by age. Among individuals who are younger, newly infected, or struggling to stay engaged in care, monitoring for AIDS-defining cancers remains incredibly important. For patients in their 40s or older, it is important to encourage participation in recommended routine screenings for colorectal, breast, prostate, and lung cancers and to monitor for other aging-related cancers, especially cancers like liver and head and neck.
We saw a higher incidence of AIDS-defining cancers and non-AIDS-defining cancers with potentially infectious causes among men with HIV compared with women with HIV. We also saw that women with HIV had elevated incidence of cancers like lung and head and neck at all ages, relative to women without HIV. This could be because these cancers are rarer among women in the general population; however, our findings reinforce that these cancers are important to consider among women with HIV.
By race, we saw differences that have been previously reported, including the finding that prostate cancer incidence differed across HIV status among non-Hispanic Black men but not among non-Hispanic White men. Hispanic beneficiaries without HIV had a lower incidence of cancer than other beneficiaries without HIV. The cause is unknown, but we cannot rule out the possibility of under-ascertainment of cancer among these beneficiaries. We further saw a noticeably higher incidence of mortality for non-Hispanic Black beneficiaries with HIV, highlighting a serious problem in terms of disparities in HIV care.
Otherwise, the patterns for the major cancer categories based on sex and race are similar across groups. Specifically, the incidence of AIDS-defining cancers increases steadily at younger ages but then largely trails off. The steady increase in the incidence of non-AIDS-defining cancers among beneficiaries with HIV across age contrasts against the pattern among beneficiaries without HIV, in whom the incidence of non-AIDS-defining cancers mainly increased after age 50.
What are the implications for clinicians?
Our results highlight what has been seen in the growing literature on chronic health conditions among people with HIV who are linked to care. These patients tend to have more chronic conditions at younger ages than those without HIV. While we did not investigate why cancer differed by HIV status, the differences are striking, and support calls for the better integration of HIV and chronic disease care.
Clinicians need to think holistically about conditions that impact people with HIV as they age, especially once a patient has well-maintained HIV. How chronic conditions like cancer interact with HIV to affect QOL and overall health is still an open question. However, in the context of cancer, encouraging preventive measures related to cancer-associated infections like HPV and risk factors like smoking, as well as routine cancer screening, are incredibly important for addressing the higher cancer burden among people with HIV.
What would you like to see future research focus on?
Differences in cancer incidence by HIV status have now been reported across multiple important populations of patients with HIV, including adults aged 65 or older enrolled in Medicare and low-income adults under 65 (our study sample). Future work is needed to determine the mechanisms leading to these differences on a cancer-by-cancer basis.
