HIV update - 20th June 2018

Cancer

People living with HIV may be vulnerable to cancers for a number of reasons:

• Some cancers occur more frequently when the CD4 count is very low and the immune system is severely damaged. This particularly relates to those cancers described as ‘AIDS defining’: Kaposi’s sarcoma, non-Hodgkin lymphoma and invasive cervical cancer.
• HIV itself may promote the development of some cancers through inflammation or over-activation of the immune system.
• People with HIV may also have a higher prevalence of risk factors for some cancers, including smoking, human papillomavirus (HPV) infection or viral hepatitis.
• People with HIV are also vulnerable to the same cancers that affect everyone else, such as prostate cancer or breast cancer.

However, there has been some uncertainty about the extent to which long-term HIV treatment and viral suppression reduce the risk of cancer developing in people living with HIV. To answer this question, American researchers have compared cancer rates in over 42,000 HIV-positive military veterans and a comparable group of 104,000 veterans without HIV.

The sample was overwhelmingly male, half were black, and two-thirds were smokers or ex-smokers.

The researchers calculated the average number of cancers that were diagnosed each year for every thousand people included in the study:

• 7 cancers in those without HIV.
• 11 in people living with HIV who had had a suppressed viral load (below 500 copies/ml), continuously for at least two years.
• 14 in people living with HIV who had had a suppressed viral load, continuously for less than two years.
• 17 in people living with HIV whose viral load was not suppressed.

The lower rate of cancers in those with a suppressed viral load was largely due to there being fewer AIDS-defining cancers. There was also some decline in the rate of cancers caused by viral infections (such as throat and anal cancers caused by HPV, or liver cancer caused by viral hepatitis).

The researchers say that more research is needed to determine whether having a viral load below 50 copies/ml rather than 500 copies/ml makes any difference to the risk of developing non-AIDS cancers. Future studies should also find out whether having a suppressed viral load for more than two years further reduces cancer risk. Finally, studies to compare cancer rates in men and women are needed.

To find out which cancers are most common in people living with HIV, read the 31 January edition of HIV update. For more information, read NAM’s factsheet ‘Cancer and HIV’.

Transmitted drug resistance

Increasing numbers of people starting treatment have a virus that is already resistant to some anti-HIV drugs, but this is unlikely to affect the success of first-line treatment in the future, according to American researchers. People rarely had resistance to newer drugs – it was more often drugs that are no longer being used that would be affected.

The data come from over 4000 people in California who started HIV treatment between 2003 and 2015. Overall, 14% had drug resistance before starting treatment. This indicates that when HIV infection occurred, the person picked up a strain of HIV that was resistant to some drugs.

The most common form of resistance was to drugs from the non-nucleoside reverse transcriptase inhibitor class (NNRTIs), especially efavirenz and rilpivirine. This affected 7.2% of people starting treatment. In addition, 5.8% of people had resistance to nucleoside reverse transcriptase inhibitors (NRTIs), especially the older drug zidovudine. Protease inhibitor resistance was less frequent (3.2%) and overwhelmingly associated with protease inhibitors no longer in clinical use.

No resistance to integrase inhibitors was reported. These are often now the preferred drugs for first-line treatment.

The profile of older, rather than newer, drugs suggests that most drug-resistant strains are being transmitted by people who themselves acquired those strains when they became HIV positive. In many cases, resistant strains were transmitted by people who have never taken treatment. Relatively few people appear to be developing resistance to modern drugs and passing it on.

Find out more about resistance in NAM’s booklet ‘Taking your HIV treatment’.

Frailty

‘Frailty’ is a term doctors use to describe a general decline in physical health and a loss of reserves, especially in older people. This leads to a person being less robust and less able to bounce back after an adverse event. A person with frailty may move more slowly, have lost some of their physical strength, have less energy and be less mentally agile. Frailty tends to get worse after each period of poor health or mental stress.

American researchers have studied frailty in men in their fifties and sixties, comparing men living with HIV and a comparable group of men who didn’t have HIV. Multiple characteristics of frailty were assessed, including unintentional weight loss, self-reported exhaustion, slow walking speed, low levels of physical activity and weak hand grip strength.

They found that frailty was twice as common in the men living with HIV (16%) than in the men without HIV (8%).

Men with excess fat around the waist, a loss of muscle mass or low bone mineral density were more likely to be frail, whether or not they had HIV. These conditions were more common in those living with HIV, many of whom had several of these problems at the same time. Ongoing inflammation and immune activation (an unhelpful response of the immune system to HIV infection) may contribute to these conditions, the researchers say.

To lower the risk of frailty developing, it’s good to be mobile and as physically active as possible. This can help you maintain your muscle and bone strength, as well as your independence.

If frailty is a problem, a comprehensive, holistic assessment by a healthcare professional can often identify changes that could help reduce frailty. These could include exercises, changes to your diet, nutritional supplements or changes to medication (sometimes, drug interactions can cause problems).

The spread of TB to close contacts

People who live in the same household and other close contacts of people with active pulmonary tuberculosis (TB) are at risk of acquiring TB, especially during the first few weeks, according to an American study.

The researchers looked at 718 people with TB and 4490 of their close contacts – people who shared airspace with the person for at least 15 hours a week. They found that 4% of close contacts acquired TB. Children under five years of age were at greater risk of acquiring TB than other people.

Half of TB cases were identified within a month of the first person’s diagnosis. Three-quarters were identified within three months.

The rate of TB transmission reported here was higher than in previous studies, many of which were done several decades ago. But it confirms much of what we already know about TB transmission.

You need to spend a lot of time in close contact with someone with active TB to be at risk of infection. People are most at risk if they live together, especially in crowded conditions, and if they have a weakened immune system. This may be from a low CD4 cell count or other health problems, but can also include people who are very young or very old.

Household members and other close contacts of a person with active TB need to be tested to check they haven’t picked up the infection.

For more information, read NAM’s illustrated leaflet, ‘How TB is passed on’.