By Steve Blanchard - May 09, 2023
Every day, patients buzz in and out of the clinic on the first floor of Moffitt Cancer Center’s Magnolia campus. They are picking up medications to ensure their T cell counts are high enough to continue receiving infusion and compatible with their ongoing cancer treatments. These patients are part of a special population. Many have already faced a battle for their lives against one disease. Then, they were diagnosed with cancer.
Treatment for human immunodeficiency virus (HIV) has come a long way since the AIDS epidemic of the 1980s. HIV and AIDS, which stands for acquired immunodeficiency syndrome, are no longer a death sentence thanks to the introduction of antiretroviral medications in the mid-1990s. A once-life-ending diagnosis has become a chronic condition, where a majority of patients can live normal, healthy lives.
However, as the HIV population ages with improved treatments, they face the growing burden of being diagnosed with other chronic conditions such as cancer. In 2021, Moffitt opened a clinic that is uniquely tailored to the needs of patients who are living with HIV and battling cancer. It’s a way to monitor the delicate balance of cancer treatment and HIV medications.
“We have seen more than 300 patients in the last two years who are HIV-positive and seeking cancer treatment at Moffitt,” said Anna Coghill, Ph.D., an epidemiologist who studies the intersection between HIV and cancer.
From One Battle to Another
For many years, people who were winning their fight against HIV found that they had fewer weapons when it came to fighting cancer.
“The guidelines now state that cancer treatments should not be withheld from HIV-positive patients,” Coghill said. “In retrospect, we’ve seen a lot of cases where this patient population was not treated as aggressively as their HIV-negative counterparts.”
That was mostly out of concern for a compromised immune system being able to handle cancer treatments like chemotherapy, Coghill said. Research has changed that perspective, though.
"The guidelines now state that cancer treatments should not be withheld from HIV-positive patients. In retrospect, we’ve seen a lot of cases where this patient population was not treated as aggressively as their HIV-negative counterparts."- Anna Coghill, Ph.D., Cancer Epidemiology Program
With improving antiretroviral treatment, many HIV-positive people are now “undetectable.” An HIV-positive patient reaches “undetectable” status when their HIV viral load is so low that HIV cannot be transmitted to sexual partners. Still, these people face a significant threat from cancer.
Approximately 1 in 4 deaths among people with AIDS are due to non-HIV-related causes, such as cancer, the National LGBT Cancer Network reports. HIV-associated cancers have dramatically increased in prevalence in long-term survivors of HIV/AIDS. They include Kaposi sarcoma, aggressive B-cell non-Hodgkin lymphoma, cervical cancer, anal cancer, Hodgkin lymphoma, lung cancer, mouth and throat cancers, liver cancer and some types of skin cancers.
Some of these cancers are linked to viruses, the American Cancer Society notes. These viruses can cause cancer in people with and without HIV, but the risk might be higher in those with HIV because their immune systems are weaker. For example, anal cancer and some mouth and throat cancers are linked to infection with human papillomavirus (HPV), the same virus that causes cervical cancer. Liver cancer is more common in people infected with the hepatitis B or C viruses. Hodgkin lymphoma is often associated with the Epstein-Barr virus (EBV). Human herpes virus 8 can cause Kaposi sarcoma, a cancer that affects the lining of the lymph or blood vessels.
“Some viruses can cause chronic infection and changes, inducing changes in some human cells,” explained Ana Velez, M.D., who specializes in infectious diseases at Moffitt. “For example, if an immune system is dysfunctional because of HIV infection, Epstein-Barr virus can cause lymphoma.”
“If the immune system isn’t strong, you can find HPV causing chronic replication in the cervix, which can lead to cervical cancer,” Velez continued. “The same can happen with anal cancer, so rectal pap smears are important in this population.”
There are also behavioral factors that can increase cancer risks for people living with HIV. For example, high smoking rates are reported in the HIV-positive community, causing a large percentage of HIV patients to develop lung cancer. This, combined with the increasing average age of the HIV population in the United States, has contributed to lung cancer emerging as one of the two most common cancers expected to be diagnosed in HIV patients in the coming decade.
Coghill also stresses the importance of regular cancer screenings for older people living with HIV. In 2019, she was part of a team that explored whether cancer treatments had an impact on outcomes in this population. The study used data from the Medicare database (patients 65 or older) to demonstrate that older HIV-positive patients had a higher mortality rate after cancer diagnosis than their HIV-negative counterparts, particularly for common tumors such as breast and prostate cancer.
“As the HIV population continues to age, the association of HIV infection with poor breast and prostate cancer outcomes will become more important, especially because prostate cancer is projected to become the most common malignancy in the HIV population,” Coghill said. “It is why we are stressing the need for more research on clinical strategies to improve outcomes for HIV-infected cancer patients.”
Early Detection and the Right Practitioner Are Key
Like with all cancers, knowing what to look for and detecting irregular cells early is the key to prevention and successful treatment. But for patients with HIV, finding the right general practitioner who knows what to look for can be challenging.
“Some oncologists are very good at knowing which cancers are associated with HIV,” Velez said. “Part of the guidelines is to test HIV-positive patients at least once in their life, or even once a year if they have risk factors for infection. Many providers don’t test or discuss this unless a patient asks.”
“If a patient and his or her care provider is on top of their care, screening happens regularly and that allows us to detect suspicious cancers much earlier,” Velez continued. “This also gives us more opportunities to collect data and learn more about this patient population to continue improving the care we provide as a cancer center.”
New HIV treatments, for example, have been found to have limited or no interactions with chemotherapy drugs. This means a patient can continue their HIV treatment even while undergoing cancer care.
Injectable antiretrovirals are especially important for people living with HIV who are diagnosed with cancer. Coordinating those drugs with a pharmacist can help reduce or eliminate complications.
“If you learn you are positive, it’s so important to begin taking your medications right away,” Velez said. “That’s even more important if you are also diagnosed with any kind of cancer.”
Keeping the immune system as strong and stable as possible can only help with the treatment outcome, Coghill stresses.
“The goal is to be undetectable, of course,” Coghill said. “Someone should always be on antiretroviral therapy, but there’s not a whole lot of good data on what happens to HIV counts. CD4 numbers drop with chemotherapy, regardless of HIV status, so that drop doesn’t necessarily mean an interruption to cancer care. Cancer therapy is quite harsh, so we need patients to be as immune competent as possible.”
CD4 cells are a type of white blood cell that helps the body fight infection. In the past, CD4 count cutoffs had been used to exclude HIV-positive patients from clinical trials, Coghill says. But the National Cancer Institute no longer recommends that.
Improving Options for Care
More research is needed to improve cancer treatment among this patient population. Several clinical trials are available for patients with anal cancer and HIV, for example. One such clinical trial is made possible through the AIDS Malignancy Consortium (AMC) and the oversight of Moffitt colorectal surgeon Julian Sanchez, M.D.
“Cancer is now the second-leading cause of death among people living with HIV, and we need to better understand what having two chronic comorbidities means for patients in terms of appropriate therapy and survival,” Coghill said. “The objective of this consortium is to bridge the gap between persons living with HIV and cancer clinical trials. The support we receive from the AMC will allow us to expand our work and offer more innovative trials to our patients.”
Securing those patient participants to help improve outcomes is sometimes difficult. Many patients don’t want to share their HIV status because of the stigma attached to the diagnosis. Patients who are newly diagnosed with HIV are sometimes depressed or embarrassed. The stigma can be difficult to overcome.
“Sometimes they get very depressed and feel shamed,” Velez said. “We sometimes have to educate them, remind them that a diagnosis like this is not a death sentence. However, we must also share with them that if they aren’t compliant with their HIV medications, their cancer can get worse.”
Moffitt strives to take some of the burden off patients who are facing this double diagnosis. Different grants are available to assist patients with medications, and Moffitt has team members in place to help HIV patients with cancer navigate their insurance. Clinicians are also on hand to suggest and recommend clinical trials that could benefit the patient ― and many more in the future.
Coghill and Velez are working with their colleagues to develop a database that will help identify people living with HIV who are receiving care at Moffitt. This will ensure that oncologists are aware of all relevant information and allow those patients with HIV unique access to clinical trials.
“Research has shown that cancer patients with underlying HIV infection are more likely to have poor outcomes, so knowledge of patient HIV status is imperative at the start of cancer therapy,” Coghill said.
Patients with HIV have long been excluded from clinical trials, especially ones involving immunotherapies that bolster the immune system to fight cancer. Moffitt is working to open clinical trials specifically for HIV-positive patients with anal cancer, lymphoma and lung cancer.
HIV and Cancer Clinic Helps Overcome Barriers
In the past, patients who had both HIV and cancer needed to bounce around to receive their care and medications from different locations. Moffitt has changed that with its HIV clinic.
Having a clinic dedicated to patients with HIV and cancer has removed some barriers. It has also helped Coghill with her research.
“We don’t always have all the HIV information for these patients,” Coghill said. “We only treat cancer. So when we look at medical records to answer research questions, we don’t always have a great history to work from. Integrating that HIV care at Moffitt is proving promising.”
Most of Coghill’s work focuses on molecular epidemiology. She is studying the differences between HIV-positive and HIV-negative cells and learning why their responses may differ. Other Moffitt researchers are focused on improving these patients’ quality of life and helping patients navigate two types of health care at once.
While for many, HIV and AIDS seem like conditions that are buried in the history of the 1980s and 1990s, Coghill and Velez point out that there are still many people who are newly infected each year. Florida has one of the highest HIV transmission rates in the country, trailing only the District of Columbia and Georgia. Knowing a patient’s HIV status can help doctors prepare a treatment plan that will not only bring comfort to the patient, but hopefully one day find a cure.
“There is hope for cancer patients who also have HIV,” Velez said. “It depends on what someone is diagnosed with, but I had one patient who had Kaposi sarcoma years ago that was related to AIDS. He started taking the right medications and is doing great. He’s been in remission for 15 years!”
This article originally appeared in Moffitt’s Momentum magazine.