This Week in HIV Research: The Challenges of Our Assumptions
Some of our most important advances in medical science occur when we challenge our assumptions. That’s been true of HIV since we first discovered what we erroneously termed “gay-related immune deficiency,” and we continue to improve our medical care of people living with HIV (PLWH) by probing at the weak points in our scientific knowledge and using rigorous science to confirm or counter our beliefs.
Much of the research we focus on in this week’s review of peer-reviewed, published studies involves pushing back against prior presumptions regarding health risks and interventions among people with HIV. Our selected manuscripts include:
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New data on anal lesions and recurrence frequency among women (not men) living with HIV.
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Findings on non-alcoholic fatty liver disease among lean (not overweight) HIV-monoinfected people.
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Evidence that a smoking cessation intervention had a long-term beneficial impact in a group of people living with HIV, contrary to prior study findings.
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A reminder that providers need to watch out for potential non-lymphoid cancer occurrence among people with HIV who have previously developed a lymphoid malignancy.
We won’t assume you’ll keep reading to learn more about each of these findings—but we sure hope you will. To beat HIV, you have to follow the science!
Anal Lesions Recur in Majority of Previously Treated Women With HIV
Anal cancer risk is often underappreciated in women, an observation supported by a relative dearth of research in this area compared to men. A recent retrospective study based in Boston, Massachusetts, sought to fill part of this gap by focusing on recurrence of anal histologic high-grade squamous intraepithelial lesions (HSIL) among women living with HIV (WLWH).
Researchers reported in Journal of Acquired Immune Deficiency Syndromes on 45 women living with HIV who had been treated for anal HSIL, a potential cancer precursor. Similar to studies in men who have sex with men, they found high recurrence rates for these lesions: 29% showed anal HSIL again 12 months after initial treatment, 52% did so at 24 months, and 79% at 36 months.
WLWH are at a 10-fold higher risk for that anal cancer than women in the general population, the study authors said. Health care providers need to be aware of this increased risk, and optimize screening and surveillance for HSIL in WLWH, they recommended. In particular, continued surveillance after initial treatment for HSIL is warranted.
Non-Alcoholic Fatty Liver Disease Not Limited to Overweight PLWH
Screening for non-alcoholic fatty liver disease (NAFLD) among PLWH should be expanded to include normal-weight PLWH with abnormal metabolism or elevated alanine aminotransferase (ALT), researchers suggested in Clinical Infectious Diseases.
Their study included 1,511 participants from three distinct cohorts focusing on liver disease among people with HIV, two of which took place in Italy and one of which took place in Canada. None of the participants were coinfected with hepatitis C.
In total, 57% of all participants were considered lean (i.e., not overweight or obese), and 24% of lean participants had NAFLD, for an overall prevalence of 14% for lean NAFLD. A higher proportion of lean participants with NAFLD had significant liver fibrosis – which can lead to liver cancer – than overweight/obese participants with NAFLD. Age, triglycerides, and ALT levels were associated with lean NAFLD.
Normal-weight people with this condition may have a different metabolism than their overweight peers or underreport their alcohol consumption, study authors hypothesized. Health care providers should therefore consider screening older PLWH with dyslipidemia and elevated ALT for fatty liver, even if they are not overweight or obese, they recommended.
Study authors also called for further research that includes specific antiretroviral treatment regimens, body fat distribution, and insulin markers, among other characteristics not available in this study.
Group Therapy Smoking Cessation Effective Long-Term Among PLWH
A small survey published in Journal of Acquired Immune Deficiency Syndromes found long-term improvements in tobacco abstinence self-efficacy among PLWH after group therapy. The findings run contrary to a prior meta-analysis that had found little long-term success of smoking cessation programs among PLWH.
The Positively Smoke Free group therapy randomized controlled trial included 342 participants in the Bronx, New York, 194 of whom were successfully located for follow-up. Mean time to the follow-up survey was 38 months after initial trial enrollment.
Using a conservative intention-to-treat analysis in which people who were lost to follow up were counted as continuing to smoke, the researchers nonetheless found a higher likelihood for biochemically verified point-prevalence abstinence at seven days (odds ratio 2.06) and 12 months (2.61) among participants who received the group therapy compared to participants who did not.
“These findings challenge the view that tobacco treatments in PLWH smokers produce short-term but not long-term cessation benefits, and suggest a role for later assessment timepoints in future studies of tobacco treatments for PLWH,” study authors concluded.
In PLWH, Higher Risk of Second Cancer After Lymphoid Malignancy
PLWH diagnosed with lymphoid malignancies are at increased risk for a second non-lymphoid cancer, according to an analysis of data from linked U.S. HIV and cancer registries that was published in AIDS.
The study included 531,460 PLWH, 6,513 of whom had a first lymphoid malignancy. The adjusted hazard ratio (aHR) for a second non-lymphoid cancer was 2.7 overall, with an especially high aHR for myeloid malignancies (9.7).
Development of lymphoid malignancies in PLWH indicates compromised immune status, which in turn may increase the risk of other cancers. Chemotherapy for treatment of lymphoid tumors is known to increase the chance of myeloid tumors independent of HIV serostatus.
Study authors recommended that health care providers be aware of PLWH’s risk for developing a second cancer and prioritize immune restoration and cancer prevention through vaccinations and smoking cessation. While screening for cervical, anal, and liver cancer facilitates early detection of these malignancies, it should be weighed against the risk of over-diagnosis and treatment-related adverse effects, the authors noted.