There were approximately 20 presentations at this conference on the causes of death in HIV-infected persons. About half the presentations were from resource-poor areas. These studies presented information quite familiar to those of us who were studying HIV infection in the 1980s and early 1990s -- deaths in resource-poor areas were due to Pneumocystis pneumonia, cryptococcal meningitis, etc. In contrast, the reports from resource-rich areas show an important shift. As HAART increasingly staves off death by HIV-caused infections, and as our HIV-infected population ages, malignancies are affecting an increasing fraction of our patients. Paradoxically, HAART could be increasing the malignancy rates by keeping our patients alive longer, thereby increasing their risk for malignancies.

Because we can neither randomize HIV infection nor randomly withhold the administration of treatment, we have to rely on careful analyses of observational cohorts to discover whether it is HIV that is somehow responsible for these malignancies, or whether they are simply normal risks of aging. This study is one of the best presented at this conference.

In their cross-sectional study, Miguez-Burbano et al analyzed 534 HIV-infected persons admitted to Jackson Memorial Hospital in Miami, Fla., between 2001 and 2002. Fifteen of the patients had one or more malignancies. Four cases of Kaposi's sarcoma occurred in men who were more likely to be HAART-untreated than the whole cohort. The four patients with lung cancer were smokers, and half were women. Four patients were diagnosed with lymphoma, and single cases of colon cancer, hemangioma and pancreatic cancer were present.

Although the study did not go into depth on this issue, it is clear that there has been a shift in the causes of death during the HAART era. Those who enter treatment late are developing lymphomas and Kaposi's sarcoma. But even in well-managed patients, a new concern has arisen -- HIV-infected smokers are beginning to develop lung cancer, and all patients whose life has been prolonged are beginning to develop the malignancies that accompany older age.

Miguez-Burbano presented more anti-smoking information elsewhere at this conference,¹ reporting that the incidence of renal failure seems much higher in smokers. In an interview, the author observed that smoking seems to change the filtration capacity and blood flow of the kidneys. As if we didn't already have a strong basis for our anti-smoking efforts.

Footnote

1. Miguez-Burbano MJ, Rodriguez A, Hadrigan S, Azor C, Shor-Posner G. Renal disease in HIV infected subjects: the deleterious effect of smoking. In: Program and abstracts of the XV International AIDS Conference; July 11-16, 2004; Bangkok, Thailand. Abstract MoPeB3274.