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Early antiretroviral therapy reduces the risk of infection-related cancers
Keith Alcorn, 2016-02-25 21:40:00
People who started antiretroviral therapy at a CD4 cell
count above 500 had a significantly lower risk of developing a cancer with an
infectious cause when compared to people who started treatment at a CD4 count
of 350 or below, an analysis of the START study presented at the Conference on
Retroviruses and Opportunistic Infections in Boston has shown.
The primary analysis of the START study showed that early
treatment reduced the risk of cancer by 64% but did not differentiate between
cancers of infectious and non-infectious causes. The analysis presented today
showed that early treatment reduced the risk of infection-related cancer by
approximately 75% and halved the risk of non-infection-related cancers.
Cancers of infectious causes include those related to human
papilloma virus (cervical cancer, anal cancer and cancers of the head and
throat), Kaposi’s sarcoma (HHV-8), Hodgkin lymphoma and non-Hodgkin lymphoma
(Epstein-Barr virus). The viruses that contribute to the development of these
cancers are more prevalent in many populations of people living with HIV and so
the prevention of these cancers is a particular priority in people living with
The START study randomised people with HIV with CD4 cell
counts above 500 cells/mm3 to start treatment immediately or defer
treatment until their CD4 cell counts fell to 350 cells/mm3 or
study found that early treatment reduced the risk of serious AIDS-related
events, serious non-AIDS events and death by 57%, and the risk of
developing any cancer by 64%. When the findings were presented in 2015
investigators said that they found no difference in the impact of early
treatment on cancers of infectious or non-infectious cause, but the analysis
presented today has revisited the question in more detail.
Fourteen people in the immediate-treatment arm developed
cancer (6 infection-related and 8 infection-unrelated) compared to 39
people in the deferred-treatment arm, a reduction in risk of 74% (Hazard Ratios
[HR]: 0.26; 95% confidence interval 0.11-0.64, p=0.003) for infection-related
cancers and 51% for non-infection related cancers (HR 0.49; 95% CI 0.21-1.15).
Twenty-nine cancers with an infectious cause
occurred (six in the immediate arm and 23 in the deferred arm). These were
predominantly Kaposi’s sarcoma (11 in the deferred arm and one in the immediate
arm) and non-Hodgkin lymphoma (nine in the deferred arm and one in the
immediate arm). There was one case of Hodgkin lymphoma in each study arm, one
case of anal cancer and one case of cervical cancer in the immediate arm and two
cases of anal cancer in the deferred arm.
Twenty-four cancers with a non-infectious cause
occurred (eight in the immediate arm and 16 in the deferred arm). Prostate and
lung cancer occurred more frequently, and a wider range of cancers occurred in
the deferred arm, but there was no substantial difference in the incidence of
any particular cancer between the two arms.
Whereas the annual cancer rate remained stable
in people in the immediate group, the annual incidence of both infectious and
non-infectious cancers increased over time in the deferred group.
Independent predictors of infection-related
cancer were older age (1.42; 0.99-2.02 per 10y), higher BMI (1.08; 1.01-1.16
per Kg/m2), low income region (0.32,
0.14-0.74 for high vs low income) and HIV RNA (2.32; 1.35-3.98 per 1log
higher). Older age was the only independent predictor of infection-unrelated cancer
(2.58; 1.75-3.81 per 10y).