Anti-HIV treatment improves survival in patients with Hodgkin's lymphoma

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 1^st 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.