Solving the HIV-Cancer Connection
Sylvester is taking steps to minimize cancer risks for higher-risk HIV patients through education, screening and early detection.
People infected with human immunodeficiency virus (HIV) can largely control its devastating health effects and live longer with approved antiretroviral therapies. However, effective HIV control does not ameliorate the higher risk of cancer for HIV patients.
“The immune system is well controlled on the medication for HIV and, theoretically, these people shouldn’t be more affected by malignancies than other people,” said Sylvester Comprehensive Cancer Center researcher Isabella Rosa-Cunha, M.D., associate professor of infectious diseases at the University of Miami Miller School of Medicine. “That’s probably true for most cancers, but certain types of cancers affect people living with HIV more than the general population.”
Factors contributing to increased cancer risk include noncompliance or lack of access to HIV treatment and the advancing ages of those with HIV, according to Sylvester researcher Emmanuel Thomas, M.D., Ph.D., who in 2022 was appointed to the National Institutes of Health’s (NIH) Coinfections and HIV Associated Cancers study section.
It’s also possible that immune systems weakened by years of fighting HIV are susceptible to cell-level mutations and vulnerable to certain types of cancer, according to Dr. Rosa-Cunha. She has joined Sylvester colleagues in the AIDS Malignancy Consortium, a National Cancer Institute (NCI) branch dedicated to the study of malignancies in people living with HIV.
The HIV-Cancer Connection in South Florida
Concerns about increased cancer risks are especially high in South Florida. Miami-Dade County, for example, is the epicenter of the United States’ HIV/acquired immunodeficiency syndrome (AIDS) epidemic, accounting for one-third of new HIV diagnoses in Florida.
“There are complex reasons for this, including our being home to many racial, ethnic and sexually diverse risk groups,” Dr. Thomas said. “Because of the diversity of people in South Florida, there are great challenges to preventing HIV.”
Three HIV-associated cancers — Kaposi sarcoma, B-cell non-Hodgkin lymphoma and cervical cancer — are AIDS-defining, signaling a progression to AIDS. People with HIV are 500 times more likely to be diagnosed with Kaposi sarcoma, 12 times more likely to be diagnosed with non-Hodgkin lymphoma, and, among women, three times more likely to be diagnosed with cervical cancer, according to the NCI.
People with HIV are also at higher risk of developing non-AIDS-defining cancers, including cancers of the anus, liver, oral cavity/pharynx, and lung, as well as Hodgkin’s lymphoma.
A Closer Look at the Problem
Viruses that can coexist with HIV cause many non-AIDS-defining cancers, according to Dr. Thomas.
“HIV weakens the immune system, which reduces the body’s ability to fight viral infections that may lead to cancer,” he said. “These viruses that cause cancers include Epstein-Barr, human papillomavirus (HPV) and hepatitis B and C.”
Herpes virus 8 can cause Kaposi sarcoma, Epstein-Barr can lead to non-Hodgkin’s lymphoma, and HPV can cause cervical, anal and oropharyngeal cancers, whereas hepatitis B and C correlate with liver cancer, according to Dr. Thomas.
Controlling Cancer’s Threat
Sylvester is addressing the HIV-cancer issue with programs focused on HIV prevention, antiretroviral therapy uptake and cancer screening for people with HIV. Its Game Changer vehicles offer HIV testing and screening for associated cancers, including cervical cancer, blood cancer and rare skin cancers like Kaposi sarcoma.
“We have three mobile units that go into the communities in our catchment area, from Palm Beach County to Key West, to provide a variety of cancer screenings,” said Valerie Bethel, Ph.D., M.B.A./H.C.M., B.S.W., director, Office of Outreach and Engagement at Sylvester. “We offer HIV and hepatitis testing for individuals who might be at higher risk of contracting these diseases. We also partner with other community partners and our sister program, the Miami Center for AIDS, to refer clients who need PrEP, the prophylaxis to prevent HIV infections.”
Sylvester’s community outreach program offers counseling and referrals to local resources and cancer prevention services, and Dr. Thomas helped to launch a program at the University of Miami UHealth Tower emergency department that screens patients for HIV and hepatitis C.
“Patients get free testing for both of these viruses while they’re getting the care they need in the emergency department,” Dr. Thomas said. “This program helps us identify HIV patients who do not know they are infected so that we can notify them and link them to care. It also identifies HIV patients who aren’t on appropriate therapy, so we can help them get their HIV under control.”
Sylvester researchers are involved in studies focused on preventing cancers, like anal cancer, that afflict people with HIV more often.
Dr. Rosa-Cunha led Sylvester and Jackson Memorial Hospital sites in the nationwide ANCHOR study, which found that treating pre-cancer anal lesions significantly reduces anal cancer risk for people with HIV. Results from the study of more than 10,000 people at elevated risk for the cancer are published in the New England Journal of Medicine.
“Sylvester has established the only dedicated program for anal dysplasia in South Florida for the prevention of anal cancer,” Dr. Rosa-Cunha said.
Dr. Thomas’ lab is studying liver cancer biomarkers, including TREM-1.
“TREM-1 is associated with liver cancer development, so we’re trying to understand that molecule and its role in the development of liver cancer in order to use it as a biomarker to identify patients with hepatitis C and HIV that may be at increased risk of developing liver cancer,” Dr. Thomas said.
Cancer Prevention for People with HIV
The first step in effective prevention, according to Dr. Thomas, is adhering to antiretroviral therapy.
“Being well controlled on antiretroviral therapy definitely prevents Kaposi sarcoma,” he said.
The HPV vaccine is effective and recommended for eligible patients, as are regular screenings for cervical and anal cancer. “Patients with coinfections should closely monitor for those cancers,” Dr. Thomas said. “In the case of hepatitis C, that’s a curable virus. The best thing we can do for them is cure the hepatitis C and that significantly reduces their risk of liver cancer.”