Tearing down the false walls to HIV cancer care

In this issue of Cancer, Grover and colleagues report that, for women in Botswana with cervical cancer, curative-intent therapy with equivalent cisplatin-based radiochemotherapy is initiated independent of human immunodeficiency virus (HIV) serostatus. The investigators’ findings merit reflection not only for the implications relevant to HIV-associated cervical cancer in Botswana but, more generally, in terms of HIV-associated cancer prevention and therapeutics worldwide. The data presented demonstrate how public-private partnerships can leverage resources to improve the availability of multimodality cancer care and that dedicated caregivers can strip away the stigma of concurrent morbid conditions like HIV infection to insure undaunted access to the best available cancer treatments. It is noteworthy that access to the best treatments in Botswana includes HIV therapy on a test-and-treat basis. The rest of the world should take note of this model. In Botswana, the prevalence of HIV infection among women aged 15 to 49 years exceeds 34%. Cervical cancer and Kaposi sarcoma (both acquired immunodeficiency syndrome [AIDS]-defining conditions) are the 2 highest incident cancers in Botswana and the leading causes of cancer mortality. Cervical cancer incidence is 17.1 per 100,000 incident cases, and Kaposi sarcoma follows closely at 13.8 per 100,000 incident cases. The leading annual cancer mortality is from cervical cancer at 9.4 per 100,000 women, and death from Kaposi sarcoma is 5.6 per 100,000 Botswanans. The magnitude of the public health impact from HIV-associated cancer in Botswana would be a formidable challenge to any society. Important studies like that by Grover et al inform ways to meet these challenges. By prospectively enrolling 519 women who presented to either the Gaborone Private Hospital or the Princess Mariana Hospital gynecologic multidisciplinary clinics between 2013 and 2017 and were eligible for the study analysis, the investigators established the important clinical and laboratory features relevant to clinical decision making in patients with cervical cancer. Approximately 70% of the women had HIV infection. The ratio of HIV-infected and noninfected women was similar regardless of whether curative-intent chemoradiotherapy was initiated. In other words, the presence of HIV infection for women who presented to these facilities had no bearing on access to or the decision to start curative-intent treatment. This is an essential first step for effective HIV cancer care. In clinical trials that have specifically addressed cancer therapy in HIV-infected patients, the outcomes essentially have been equivalent to that of the background population with similar conditions and treatments. Clinical trials using intensive chemotherapy, including autologous and allogeneic transplantation for myeloid and lymphoid cancers, have demonstrated that, when the same therapeutic approach is used to treat individuals who are living with HIV and otherwise are eligible for a given type of therapy, there are no apparent differences in tolerance to or benefit from therapy compared with the background population. In contrast, numerous survey studies relying on incomplete clinical data derived from matching cases from HIV and cancer databases have consistently reported poorer outcomes among individuals who have HIV compared with others. What is the basis for the difference in findings between prospective studies and surveys? Suneja and colleagues observed disparities in cancer outcomes for individuals with HIV infection in the United States that shed light on this question. Outcomes were worse among HIV-infected individuals; and, for patients who had common tumors, there was a high likelihood that those with HIV did not receive curative-intent treatment. This is a complex issue. For example, in the United States, the demographics of HIV infection increasingly have involved economically disadvantaged populations, for which the stigma for both cancer and HIV infection remain high. This creates formidable barriers to HIV diagnosis and treatment, thus resulting in a large population of individuals with unknown HIV status. Delayed diagnosis for asymptomatic HIV results in no treatment until symptomatic AIDS develops; and it follows that treatment