Understanding the Interplay between HIV and Ageing, NCDs and Malignancies: Cancer in people with HIV Andrew Grulich HIV Epidemiology and Prevention Program, Kirby Institute, UNSW Australia, Sydney AIDS 2016, Durban

Disclosure research funding from CSL Australia, Gilead, Viiv, Hologic honoraria for educational presentations from Merck, Sanofi-Pasteur, Gilead and Viiv.

Smoking another key contributor to increased risk A range of infection-related cancers occurs at increased rates in PLWHIV Smoking another key contributor to increased risk Adapted from A Grulich et al, Lancet 2007

Estimated age-specific incidence rates for all cancers combined Cancer and ageing Estimated age-specific incidence rates for all cancers combined Source: Analysis of the Australian Cancer Database, 2016

Relative frequency of cancer types in PLWHIV E Lanoy et al, Int J Cancer, 2011

Excess cancer cases in 2010, PLWHIV, USA E Engels et al, JNCI 2015;107:dju503

Excess cancer cases, by transmission, PLWHIV, USA E Engels et al, JNCI 2015;107:dju503

Preventing cancer in PLWHIV: treat HIV early Maintaining close to normal immune function Severe immune deficiency greatly increases risk of lymphoma, KS. Quickly (partly) reversible, but some increase in risk remains Even mild immune deficiency increases risk of lymphoma particularly Burkitt lymphoma, Hodgkin disease

Decrease of KS risk after initiation of ARVs S Franceschi et al, Brit J Cancer 2008

Preventing cancer in PLWHIV Maintaining undetectable viral load For lymphoma, detectable virus is a cause of immune stimulation that increases cancer risk At least some of the effect appears to be independent of immune deficiency

START: Early ARV therapy reduces cancer risk J Lundgren et al, NEJM, 2015

Adapted from A Grulich et al, Lancet 2007

Preventing infection-related cancer in PLWHIV Prevent carcinogenic infections Behavioural risk reduction Clean needles, harm reduction (HIV, HBV, HCV) Condoms (HBV, partially effective for HPV) Immunisation HBV HPV

NIH guidelines

Preventing infection-related cancer in PLWHIV Treating carcinogenic infections Cure the HCV infection Treat the HBV infection KSHV/EBV no current therapeutic options but risk is low if HIV treated and immune function maintained HPV Screen and treat pre-invasive lesions of the cervix

NIH guidelines for anal cancer screening in PLWHIV “At this time, no national recommendations exist for routine screening for anal cancer. However, some specialists recommend anal cytologic screening or high resolution anoscopy for HIV positive men and women (CIII)” “An annual digital anal examination may be useful to detect masses on palpation that could be anal cancer (BIII)”

Cancer in ageing PLWHIV We will soon see new patterns of cancer in ageing people with HIV Most “cancers of ageing” are not increased in this population Key elements of reducing cancer risk are Maintenance of near to normal immunity and undetectable HIV viral load Preventing, treating or curing oncogenic co-infections Anal cancer a stand out in terms of unresolved issues Addressing lifestyle risk factors (smoking, alcohol)