Infection with HIV increases cancer incidence, especially AIDS-defining cancers (ADC) such as Kaposi sarcoma (KS). In Uganda, where HIV is endemic, incidence of AIDS-defining cancers (those that HIV+ individuals are at high risk of developing) and non AIDS-defining cancers (NADC) are on the rise despite an increase in the number of HIV patients receiving antiretroviral therapies (ART).
Little is known about HIV status among cancer patients and how frequently HIV infection complicates the presentation of cancer in sub-Saharan Africa (SSA). Patients suffering from both HIV infection and cancer or other HIV-associated malignancies require careful therapy that must consider HIV-related factors such immune cell counts, progression to AIDS, and antiviral treatment. However, standards-of-care for treating comorbidities of cancer and HIV remain undefined due to a paucity of data on HIV-associated malignancies in HIV-prevalent regions such as SSA.
Dr. Bender Ignacio, a physician-scientist and the lead researcher on a recent publication in the Journal of Global Oncology, conducted a cross-sectional study using medical records at the Uganda Cancer Institute (UCI) to determine HIV burden and how HIV infection is associated with disease progression among cancer patients. First, Bender Ignacio and colleagues surveyed records from 1,137 adults with cancer enrolled at UCI between June and September in 2015 to determine the prevalence of HIV. They found that 23% were positive, 48% tested negative, and 29% had no recorded HIV status. To tackle the problem of nearly 30 percent of cancer patients lacking an HIV test result and estimate the mean of the missing data, three different weighted imputations analyses based on sex, decade of life, or cancer diagnosis, were performed. The last method was considered to be the most accurate, as tumor diagnosis is heavily associated with patient age and sex. This method estimated that 21% of HIV+ occurrences were unrecorded, increasing the HIV prevalence among UCI patients to 29%, much higher than the overall HIV prevalence of 7.4% in Uganda. These results demonstrated that not only were many of the cancer patients at UCI infected with HIV, but that HIV incidence among cancer patients is four-fold higher than the national average, suggesting that HIV screening in cancer patients should be a high priority. Additionally, among those tested, 83% of infected individuals were reportedly receiving ART. This high frequency implies that patients who are already receiving care for HIV are more likely to be referred to UCI for cancer treatment. This may indicate that those with undiagnosed HIV or no HIV infection may be less likely to receive cancer diagnosis and treatment.
Figure provided by Dr. Bender Ignacio
Once they established HIV prevalence, the authors then sought to further define which cancers and disease progression characteristics were associated with HIV infection. They found that cancer patiengs with HIV tended to be younger with earlier stage cancers, but based on biologic markers of health, had poorer functional status than HIV-negative cancer patients, which could indicate nutritional deficiencies and other comorbidities. Additionally, patients with NADCs were less likely than those with ADCs to have HIV status recorded, although HIV prevalence was estimated to be 21% in this group. This indicated there may be a decreased tendency to test for HIV when patients present with NADCs, highlighting a population of cancer patients who may be overlooked for HIV testing and subsequent treatment. Dr. Bender Ignacio explains, saying that “much of the effort until now has been focused on the 3 AIDS-defining cancers (cervical, non-Hodgkin lymphoma, and Kaposi sarcoma), but we need to think about how to treat people with HIV who have common cancers like breast, head and neck, or gastrointestinal tumors.” Senior author Dr. Phipps elaborates, saying that the “high rates of cancer observed in HIV patients also suggests a need (and opportunity) for increased cancer screening and early detection strategies in persons living with HIV in Africa.”
This study, which Dr. Bender Ignacio indicated is “the first estimation of prevalence of HIV testing and HIV status among all patients presenting for cancer care in a sub-Saharan country,” highlights the association between ADC and NADC in HIV+ individuals in SSA and defines biologic and demographic factors associated with HIV and cancer comorbidities. Dr. Bender Ignacio suggests that future directions in this field should “include clinical trials and implementation science to learn how to optimize outcomes for both conditions in resource-limited settings,” and that “the burden of HIV is much higher than expected among cancer patients and programmatic work should be done to increase HIV testing and coordinated HIV and cancer treatment, as has recently become the norm for other co-morbid conditions, such as tuberculosis and HIV.”
Bender Ignacio R, Ghadrshenas M, Low D, Orem J, Casper C, Phipps W. 2018. HIV status and associated clinical characteristics among adult patients with cancer at the Uganda Cancer Institute. Journal of Global Oncology. (4):1-10. doi: 10.1200/JGO.17.00112
This work was funded by the Fred Hutch Global Oncology program, the National Cancer Institute, and the National Institute of Allergy and Infectious Diseases.
Fred Hutch/UW Cancer Consortium authors Corey Casper and Warren Phipps contributed to this work.