Cancer mortality among HIV-infected people with cancer has declined over time, but these deaths account for an increasing fraction of all deaths. In fact, approximately 6% of HIV-infected patients developed malignancies, and about 40% of these patients died during the study period. The emergence and improved ART access worldwide have dramatically improved the life expectancy of PLWH or People living with HIV, which is now comparable to the general population. However, malignancy among the PLWH remains a significant cause of increased mortality and morbidity. In fact, most countries with declining mortality rates are lower-income countries, except the United Kingdom.
HIV Associated Cancer Survival Rate
People with HIV and cancer have a lower survival rate than those cancer patients who are not infected with HIV. Although this high mortality rate is partly responsible for AIDS-related complications, additional suggested explanations for the difference in survival include biologically aggressive cancer phenotype, stages of cancer diagnosis, decreased efficacy of drugs due to immunomodulatory dysfunction, and increased toxicity in the body due to cancer treatment.
Another possible explanation for the low survival rate after being diagnosed with cancer is that people living with HIV may not receive appropriate cancer treatment. A study on lung cancer patients in Texas reported that people with HIV were less likely to receive cancer treatment than people without HIV and that these differences could be associated with reduced survival. However, most non-AIDS-defining cancers lack evidence-based guidelines for the treatment of HIV-infected cancer patients. This is because HIV patients are usually excluded from cancer clinical trials. Lack of guidelines can further lead to undertreatment of cancer in HIV-infected patients, leading to low efficacy or high toxicity of the chemotherapeutic drugs1.
Studies pertaining to HIV/AIDS cancer survival
The lack of cancer treatment in HIV-infected patients with non-small cell lung cancer, local-stage Diffuse large B cell lymphoma (DLBCL), and colon cancer are particularly associated with the therapeutic potential of early cancer treatment. Treatment of early-stage cancer can prevent relapse and prolong the disease-free rate of overall survival2. This problem has gained increasing importance as the overall survival rates of people living with HIV have improved. In fact, cancer mortality among HIV-infected people with cancer has declined over time, but these cancer deaths account for an increasing fraction of all deaths.
The incidence of cancer in the HIV-infected population contributed rapidly to overall mortality. According to a study, approximately 6% of HIV-infected patients developed malignancies, and approximately 40% of these patients died during the time period of the study3.
The World Health Organization (WHO) defines AIDS in people living with HIV (PLWH), either clinically (the presence of stage 4 AIDS-associated comorbidity) or immunologically (CD4 cells < 200 per mm3). However, PLWH are at increased risk for developing various malignancies in comparison to those without HIV4. In fact, in 2019, approximately 38 million people were infected with HIV, of whom 25.4 million received antiretroviral therapy (ART). Several malignancies, including Kaposi’s sarcoma, invasive cervical cancer, and also non-Hodgkin’s lymphoma, are known to develop from more advanced immunodeficiency conditions and are collectively mentioned as AIDS associated cancers5. As a result, patients infected with HIV have a 1.6–1.7-fold increased risk for developing cancer in comparison to the general population6.
Malignancies have significantly contributed to the mortality of HIV-infected people. A multinational collaborative study from 1999 to 2011 reported that AIDS associated cancer was the leading cause of death among HIV patients under treatment7. In fact, in a population-based study conducted in the United States from 2001 to 2015, the mortality among PLWH from cancer was 386.9 deaths per 100,000 humans each year. Of these deaths, 9.2% and 5% resulted from NADC and ADC, respectively5. In France, malignancy mortality rate due to HIV associated malignancy was found in 28% of HIV patients receiving ART8,9.
Since the introduction of ART in the early 1990s, increased access to the drug has been observed with the introduction of ART based treatment and the subsequent reduction in AIDS-related deaths. A similar decrease in the rate of ADCs was also observed10,11. However, the proportion of NADC in PLWH is increasing, possibly due to the increased life expectancy among PLWH8. Despite this, there is a lack of sufficient data that can explain the trend of mortality rate among HIV-infected cancer patients.
The emergence and improved ART access worldwide have dramatically improved the life expectancy of PLWH, which is now comparable to the general population. Currently, malignancy among the PLWH still remains a significant cause of increased mortality and morbidity7. In fact, according to a study conducted in France between 2000 and 2010, ADC and NADC among PLWH accounted for 10% and 26% of deaths, respectively12. In another study conducted in 31 countries, an increased male mortality rate in 13 countries (41.9%) was observed. Whereas, in the same study, increased mortality among females (44.0%) in 11 countries was observed among 25 countries. Moreover, the majority of countries with declining mortality rates were low-income countries, with the exception of the United Kingdom13.
- 1.Suneja G, Shiels M, Angulo R, et al. Cancer treatment disparities in HIV-infected individuals in the United States. J Clin Oncol. 2014;32(22):2344-2350. doi:10.1200/JCO.2013.54.8644
- 2.NCCN clinical practice guidelines in oncology. National Comprehensive Cancer Network. Published 2008. Accessed March 2022. http://www. nccn. org/professionals/physician_gls/PDF/occult. pdf.
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- 6.Park L, Tate J, Sigel K, et al. Time trends in cancer incidence in persons living with HIV/AIDS in the antiretroviral therapy era: 1997-2012. AIDS. 2016;30(11):1795-1806. doi:10.1097/QAD.0000000000001112
- 7.Smith C, Ryom L, Weber R, et al. Trends in underlying causes of death in people with HIV from 1999 to 2011 (D:A:D): a multicohort collaboration. Lancet. 2014;384(9939):241-248. doi:10.1016/S0140-6736(14)60604-8
- 8.Shiels M, Pfeiffer R, Gail M, et al. Cancer burden in the HIV-infected population in the United States. J Natl Cancer Inst. 2011;103(9):753-762. doi:10.1093/jnci/djr076
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- 10.Reniers G, Slaymaker E, Nakiyingi-Miiro J, et al. Mortality trends in the era of antiretroviral therapy: evidence from the Network for Analysing Longitudinal Population based HIV/AIDS data on Africa (ALPHA). AIDS. 2014;28 Suppl 4:S533-42. doi:10.1097/QAD.0000000000000496
- 11.Rufu A, Chitimbire V, Nzou C, et al. Implementation of the “Test and Treat” policy for newly diagnosed people living with HIV in Zimbabwe in 2017. Public Health Action. 2018;8(3):145-150. doi:10.5588/pha.18.0030
- 12.Morlat P, Roussillon C, Henard S, et al. Causes of death among HIV-infected patients in France in 2010 (national survey): trends since 2000. AIDS. 2014;28(8):1181-1191. doi:10.1097/QAD.0000000000000222
- 13.Jani C, Al O, Singh H, et al. Trends of HIV-Related Cancer Mortality between 2001 and 2018: An Observational Analysis. Trop Med Infect Dis. 2021;6(4). doi:10.3390/tropicalmed6040213