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CROI 2010 Wrap-Up: Complications of HIV and Its Treatment

A Discussion With Pablo Tebas, M.D.

March 30, 2010

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Cancer and HIV: Addressing a Growing Threat

Myles Helfand: All right. Then let's shift gears a bit, over to cancers in HIV, another area of complications that has always been a concern in HIV medicine, but the specific nature of which has changed significantly in the past decade.

AIDS-defining cancers, of course, were one of the defining features of people with advanced HIV disease in the '80s and '90s. In the more modern era of treatment, at least in developed countries, the nature of the cancers that have been diagnosed in HIV-infected people has shifted a bit, in terms of the incidence and the frequency of certain cancers -- particularly non-AIDS-defining cancers. What did we learn at CROI that might add to our knowledge of where this might be headed?

Pablo Tebas: I think this is an area we need to be concerned about. Patients with HIV are living longer, and we need to worry about the long-term consequences of living with an immune system that is good enough to protect you from opportunistic infections, but may not be completely normal [so that it would be able to] protect you from cancers and other long-term complications.

I think there were several studies [presented at CROI about this]. There was data from NA-ACCORD, which is a large cohort of North American clinics. There were studies from the CDC [U.S. Centers for Disease Control and Prevention], from the VA [U.S. Department of Veterans Affairs]. And the general theme is that not only are traditionally HIV-associated cancers increasing in HIV patients -- it's not only Kaposi's sarcoma or non-Hodgkin's lymphoma -- there are other cancers that we traditionally don't think of as HIV-related but that, in fact, their incidence is increased in patients with HIV, or they appear at a younger age in patients with HIV than in the general population. I'm talking about lung cancer, liver cancer, cancer of the anal area (that is probably associated with HPV [human papillomavirus]), melanoma. If you have HIV, your relative risk of having those cancers are probably twice, or a little bit more, than in the general population.

So there are two ways to deal with this. What does this mean for the clinician? It means, one, that probably it is a good idea to treat earlier in HIV. Because it seems that the increased incidence of this cancer is because your immune system is not completely normalized by treatment. But if you treat earlier, you will not allow your immune system to deteriorate to the point that you will lose some of these surveillance capabilities for cancer. So I think it's another one of the reasons, the growing number of reasons, that would tilt the balance to treat earlier, to try to prevent these long-term complications.

The other message is, as HIV has become more of a chronic disease, you need to be aware of this problem and stick to preventive measures: to really do your colonoscopy when you get to age 50; to really do, when you're a woman, Pap smears to rule out cervical cancer. If you are a gay man, then maybe do a Pap smear of the perianal area, to make sure that you are not going to have rectal cancer. And if you have warts, maybe have them checked more frequently by a colorectal surgeon.

I think the awareness about this problem should increase screening frequency. Make sure that you not only take care of your HIV, but also, that you have a regular internist that is going to be following up on these risks. And if you have a chronic cough, you have to have a chest X-ray to make sure that you are not developing lung cancer.

Some of my patients, what happens is that they tend to go to the HIV clinic, and they see their HIV doctor. And the HIV doctor tells them, "Oh, everything is going fine. You have an undetectable viral load, and your CD4 count is fine. Keep doing what you are doing." Well, they should be telling the patients, if they're worried about traditional risk factors for cardiovascular disease, but also cancers.

I think HIV care is becoming more and more like internal medicine, and we need to address all these issues that are being associated with living longer with well-controlled HIV.

Myles Helfand: I imagine there's a pretty delicate balance to strike here, particularly for a newly diagnosed patient who you don't want to freak out. I mean, it's probably a big enough thing for them to be dealing with their HIV diagnosis, period, and with the concept of starting antiretroviral therapy and then having to continue to take that every single day for the rest of their lives, potentially. To also throw onto that the prospect of a variety of cancers potentially developing earlier, or being more common among HIV-positive people, and the need to then get screened more frequently?

I had the opportunity to speak with Elizabeth Chiao, who presented a couple of studies on squamous cell cancer and the impact of antiretroviral therapy on maybe preventing it. One of the assertions that she had made during the conversation we had was that people don't love getting anal Pap smears. It's a difficult thing, in some cases -- and I think the same might be true of other types of cancer screenings. You're not necessarily going to get people to agree to get regularly tested for these sorts of things.

What does a clinician say to a patient who, number one, might not have thought they would have to deal with this prospect? And then, number two, might be not so thrilled with the idea of frequent cancer screenings?

Pablo Tebas: I try to have a very relaxed approach about this, and joke. I joke about my age, that I have to have my own colonoscopies. Nobody enjoys having a prostate exam, believe me. But you have to do it. You have to do screenings that have been proven to be effective -- I mean, mammograms after the age of 50, colonoscopy after the age of 50. Well, there is a big discussion about mammograms, but I mean, definitely, after the age of 50, the Pap smears.

All these types of regular screenings: I think patients with HIV shouldn't forget about them. When everything is going well in their HIV, they still have to realize that their immune system is not 100% normal, and that because of that, they need to deal with it. And the way to deal with it is to make sure that they encourage their physicians to do these regular things that we should be doing for everybody, but particularly for patients with HIV.

I try to have a very light approach to it. But I encourage my patients to have all these things done at regular intervals. And I think, for some of the big programs like Medicare or Medicaid, they should really evaluate the quality of the HIV care that clinicians provide to HIV patients -- not only by HIV markers like how many people are taking antiretrovirals or how many people are undetectable, but how good the providers are in covering all these other areas. Because overall, I think we have to have a global approach to HIV care that includes dealing with these increased cardiovascular risks. Now we're talking about the increased cancer risk in this population.

When I look at these things, I also hope that people who are not infected realize that HIV, although we have had huge improvements in antiretroviral therapy, is not trivial. Your immune system is paying a price. Yes, we have better treatments for HIV. But even if your HIV is well controlled, there are all these other increased risks that, because of HIV, are still present.

Hopefully that message gets out. Because I think the perception that HIV is a disease for the long run has been lost. I think that's at least partially the reason why we still have more than 50,000 cases of new infections a year: People don't think about the long-term consequences of having HIV. They say, "Well, if I get HIV, I will take a pill, and everything will be fine." No. Not exactly that. You still have an increased cardiovascular risk that I think we can deal with, if we do regular interventions. And you still have an increased risk in cancer that is going to make you have to go to your provider periodically.

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