Survival amongst HIV-positive individuals with Hodgkin's lymphoma has increased significantly since the introduction of effective antiretroviral therapy, according to a Spanish study published in the April 1st edition of the Journal of Acquired Immune Deficiency Syndromes. Rates of complete remission, disease free survival, and overall survival were significantly better amongst patients in the antiretroviral era. All HIV-positive patients with Hodgkin lymphoma should, the investigators argue, be treated with both anti-HIV drugs and chemotherapy.
Hodgkin lymphoma is not an AIDS-defining cancer (unlike non-Hodgkin’s lymphoma), nevertheless it occurs eight-to-ten times more frequently in HIV-positive individuals than in the general population.
Furthermore, Hodgkin's lymphoma is usually diagnosed in people with HIV at a later stage than in HIV-negative people and is more likely to involve severe symptoms.
Many doctors think that because of these factors Hodgkin's lymphoma should be considered an AIDS-defining condition, and that all patients with Hodgkin's lymphoma should be tested for HIV.
Before effective antiretroviral therapy became available, the prognosis for HIV-positive patients diagnosed with Hodgkin's lymphoma was poor. Although the impact of anti-HIV treatment on survival amongst patients with non-Hodgkin’s lymphoma has been extensively studied, there are few data on Hodgkin’s lymphoma in people with HIV.
Spanish investigators therefore looked at cases of Hodgkin's lymphoma recorded in a national registry of HIV-positive patients with lymphomas to assess survival, treatment response, and prognostic factors in HIV-positive patients with Hodgkin's lymphoma in the periods before and after effective anti-HIV treatment was introduced.
A total of 104 patients were included in the investigators’ analysis; 21 of these individuals were diagnosed with Hodgkin's lymphoma before effective anti-HIV treatment was available.
Overall 90% of patients were male, 62% became infected with HIV through injecting drug use, 35% already had an AIDS-defining condition before Hodgkin's lymphoma was diagnosed, and median CD4 cell count at the time of lymphoma diagnosis was 163 cells/mm3.
Hodgkin's lymphoma had similar characteristics in the patients diagnosed before and after anti-HIV treatment became available.
Appropriate chemotherapy was provided to 80% of patients before antiretroviral therapy was introduced and 85% after such treatment became available. The rate of complete remission (no cancer for four weeks after treatment) was 70% in the patients who did not have access to antiretroviral therapy, and 91% for patients who received effective anti-HIV treatment (p = 0.023). Over a third of the patients in the pre-HIV treatment era who went into remission subsequently relapsed, but only 9% of antiretroviral-treated patients relapsed.
Overall survival was also significantly longer for patients diagnosed with Hodgkin's lymphoma in the era after anti-HIV treatment became available (p = 0.008). The investigators also found that the rate of five year disease free survival was 76% amongst patients in the period before anti-HIV treatment was introduced, but 87% amongst patients treated with anti-HIV drugs (p = 0.045).
Further analysis showed that 66% of the patients in the pre-antiretroviral era died compared to 24% of patients after anti-HIV treatment became available. The reduction in mortality for patients in the era of anti-HIV therapy was due to a decrease in Hodgkin's lymphoma deaths.
Provision of treatment before a patient’s CD4 cell count fell below 100 cells/mm3 was associated with an increased chance of survival.
“To the best of our knowledge, our study analyzes the largest number of patients with HIV-related Hodgkin's lymphoma treated with highly active antiretroviral therapy [HAART] to date…we found that HAART significantly improved complete remission, overall survival, and disease free survival in HIV-related Hodgkin's lymphoma. We want to emphasize that patients treated or not treated with HAART were well matched in baseline characteristics”, write the investigators.
Berenguer J et al. Characteristics and outcomes of AIDS-related Hodgkin lymphoma before and after the introduction of highly active antiretroviral therapy. J Acquir Immune Defic Syndr 47: 422 – 428, 2008.