Understanding the Interplay between HIV and Ageing NCDs

Understanding the Interplay between HIV and Ageing, NCDs and Malignancies: Cancer in people with HIV Andrew Grulich HIV Epidemiology and Prevention Program, Kirby Institute, UNSW Australia, Sydney AIDS 2016, Durban

Disclosure • research funding from CSL Australia, Gilead, Viiv, Hologic • honoraria for educational presentations from Merck, Sanofi-Pasteur, Gilead and Viiv.

• A range of infectionrelated cancers occurs at increased rates in PLWHIV • Smoking another key contributor to increased risk Adapted from A Grulich et al, Lancet 2007

Cancer and ageing Estimated age-specific incidence rates for all cancers combined Source: Analysis of the Australian Cancer Database, 2016

Relative frequency of cancer types in PLWHIV E Lanoy et al, Int J Cancer, 2011

Excess cancer cases in 2010, PLWHIV, USA E Engels et al, JNCI 2015; 107: dju 503

Excess cancer cases, by transmission, PLWHIV, USA E Engels et al, JNCI 2015; 107: dju 503

Preventing cancer in PLWHIV: treat HIV early Maintaining close to normal immune function • Severe immune deficiency greatly increases risk of lymphoma, KS. – Quickly (partly) reversible, but some increase in risk remains • Even mild immune deficiency increases risk of lymphoma – particularly Burkitt lymphoma, Hodgkin disease

Decrease of KS risk after initiation of ARVs S Franceschi et al, Brit J Cancer 2008

Preventing cancer in PLWHIV Maintaining undetectable viral load • For lymphoma, detectable virus is a cause of immune stimulation that increases cancer risk • At least some of the effect appears to be independent of immune deficiency

START: Early ARV therapy reduces cancer risk J Lundgren et al, NEJM, 2015

Adapted from A Grulich et al, Lancet 2007

Preventing infection-related cancer in PLWHIV Prevent carcinogenic infections • Behavioural risk reduction – Clean needles, harm reduction (HIV, HBV, HCV) – Condoms (HBV, partially effective for HPV) • Immunisation – HBV – HPV

NIH guidelines

Preventing infection-related cancer in PLWHIV Treating carcinogenic infections • Cure the HCV infection • Treat the HBV infection • KSHV/EBV – no current therapeutic options but risk is low if HIV treated and immune function maintained • HPV – Screen and treat pre-invasive lesions of the cervix

NIH guidelines for anal cancer screening in PLWHIV • “At this time, no national recommendations exist for routine screening for anal cancer. However, some specialists recommend anal cytologic screening or high resolution anoscopy for HIV positive men and women (CIII)” • “An annual digital anal examination may be useful to detect masses on palpation that could be anal cancer (BIII)”

Cancer in ageing PLWHIV • We will soon see new patterns of cancer in ageing people with HIV • Most “cancers of ageing” are not increased in this population • Key elements of reducing cancer risk are – Maintenance of near to normal immunity and undetectable HIV viral load – Preventing, treating or curing oncogenic co-infections • Anal cancer a stand out in terms of unresolved issues – Addressing lifestyle risk factors (smoking, alcohol)