1. 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

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

3. 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

5. 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

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

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

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

9. 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

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

11. 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

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

13. Adapted from
A Grulich et al, Lancet 2007

14. 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

16. NIH guidelines

17. 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

19. 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)”

20. 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)