Treatment

People who have a higher CD4 cell count at diagnosis, whose Hodgkin's disease is restricted to the lymph nodes and who have not had previous opportunistic infections, have the best prognosis. All HIV-positive patients diagnosed with Hodgkin's lymphoma should begin antiretroviral therapy if they are not already taking it, since antiretroviral treatment improves prognosis. 

Early Hodgkin's disease (stages I and II) is usually treated with radiotherapy. More advanced Hodgkin's disease (stages III and IV) is treated with combination chemotherapy, using either MOPP (chlormethine, vincristine [Oncovin], procarbazine and prednisolone) or ABVD (doxorubicin [Caelyx / Myocet], bleomycin, vincristine and dexamethasone [Decadron]). In the UK the British HIV Association recommends ABVD.

Given low rates of disease-free survival using these regimens in HIV-infected people, a more potent regimen has been tested. Known as Stanford V, the regimen includes mechlorethamine, doxorubicin, vinblastine (Velbe), vincristine, bleomycin, etoposide (Etopophos / Vepesid) and prednisolone administered over a 12-week period. Radiotherapy and highly active antiretroviral therapy (HAART) may be used in conjunction with Stanford V. One study of Stanford V plus antiretroviral therapy in 20 HIV-infected people with Hodgkin's disease found that dose reductions due to side-effects were common. Nevertheless, disease-free survival rate at 18 months was 61%. Stanford V is currently recommended in the UK only through a clinical trial.

A recent study has demonstrated that autologous haematopoietic stem cell transplantation is safe and effective in HIV-positive patients being treated with HAART and with high-dose chemotherapy for Hodgkin's disease. This technique involves removal of stem cells from the bone marrow or blood of a patient before chemotherapy. Once the chemotherapy is finished, the cells are transplanted back into the patient. The transplanted cells have the ability to produce new blood cells and aid the reconstitution of the immune system by replacing the cells that are killed during the course of drug treatment.¹

Chemotherapy is difficult for HIV-infected people to tolerate. Treatment may be better tolerated when the growth factors granulocyte macrophage colony stimulating factor (GM-CSF) and granulocyte colony stimulating factor (G-CSF) are given.

Current UK treatment recommendations for Hodgkin's lymphoma in HIV-positive people are outlined in the British HIV Association's HIV-associated malignancy guidelines, available at www.bhiva.org.