Advances in HIV Treatment Pose New Risks for Patients

David Henry, MD

David H. Henry, MD, is a medical oncologist, medical director of the Penn HIV oncology program  and vice chair of the department of medicine at Pennsylvania Hospital. Today, December 1 on World AIDS Day, Dr. Henry discusses how treatment for HIV has evolved since its discovery in 1981, and how patients with HIV may be at an increased risk for cancer.

Since its discovery in 1981, treatment for the human immunodeficiency virus or HIV has quickly evolved. In humans, HIV leads to progressive failure of the immune system (immunosuppression), allowing life-threatening opportunistic infections and cancers to thrive.

While for many of us it seems like yesterday this epidemic appeared, most young doctors and nurses in training today have never known a time without HIV.

When it first became apparent HIV was an epidemic, there was no therapy to stop the consequences of profound immunosuppression. Patients rapidly developed full-blown AIDS (acquired immune deficiency syndrome) and died of unusual, opportunistic infections. Back then, I recall losing as many as three patients a month to AIDS. 

When AZT (azidothymidine), the first therapy for AIDS was developed, it began to change the natural course of HIV. But it wasn’t until the more powerful protease inhibitor drugs that were developed in late 1995 that patients were restored to much greater immunity and could avoid opportunistic infections.

Now with at least five classes of antiretroviral therapies, many patients with HIV enjoy a life without opportunistic infections. They have undetectable viral loads and experience significant elevations in their CD4 immune defenses.

However, this major advance in antiretroviral therapy and improvement in longevity has led to a new issue for people with HIV — cancer. 

From the beginning, physicians and researchers knew that profound immunosuppression led to early/frequent development of so-called AIDS-defining cancers:

• Kaposi’s sarcoma
• Non-Hodgkin lymphoma
• Cervical cancer

With highly active antiretroviral therapy, these AIDS-defining cancers are much less frequent, but several non-AIDS-defining cancers have become much more prevalent:

• Anal cancer: One hundred times more likely in the HIV-infected patient
• Liver cancer: Usually associated with co-infection with hepatitis B and/or C
• Lung cancer: By sheer numbers of new cases, may be the greatest problem of all

All of these cancers tend to occur at a younger age than they would in non-HIV-positive people. Anal, hepatic and lung cancer, occur five to 10 years earlier in the HIV-infected population than in those who are not.

Currently, there are no known strategies, drugs or therapies for stable HIV-infected patients that would restore their immunity completely and lower these cancer rates back down to that of the general population.

However, we are developing screening strategies to detect cancer and treat it earlier. 

Smoking cessation and possibly low-dose CT scanning may decrease or catch lung cancer in a more curable stage. Every six to 12 months, imaging of the liver in patients co-infected with hepatitis C and/or B can help identify liver cancer earlier. Routine anal examination and possibly even Pap testing can help discover anal cancer at an earlier, more curable stage.

HIV treatment has certainly come a long way, but vigilance, surveillance, treatment, and better understanding of cancer has become the next major challenge in this ever-present epidemic.

Learn more about the HIV oncology program at Penn Medicine.

Learn more about AIDS research at Penn Medicine.