Characteristics, Social Factors, and Trends in HIV and AIDS-Related Lymphoma: A 23-Year Analysis Since the Implementation of c ART, a County Hospital AIDS Malignancy Project (CHAMP) Study
Authors: Demarco Camille E. , Lu Pei , Peace David F. , Singh Sunny , Angelov Dennis F. , Benante Kelly A. , Ahmed Ahmed T. , Rubinstein Paul G. 
Published: October 2019

Abstract
Introduction: Stroger Hospital (CCH) and the Ruth M. Rothstein CORE Center (CC) are the largest health providers for HIV+ patients (pts) in Chicago and one of the largest HIV clinics in the United States. CCH/CC treat approximately 5,000 HIV+ individuals per year and 40 newly diagnosed HIV-associated cancers annually. The CHAMP Study was originally a retrospective database from 1990 to 2010 of all clinical, demographic, cancer characteristics of pts diagnosed with HIV/AIDS. Since then, the study has compiled data prospectively on all pts with hematological malignancies. In this study, we analyzed various characteristics of pts with HIV/AIDS diagnosed with lymphoma as well as changes seen over time including therapy response since the implementation of combined anti-retroviral therapy (cART). In addition, we assessed variables including drug use, psychiatric history (hx) and time of HIV diagnosis (dx) with respect to cancer presentation. While large population studies of HIV and cancer exist, few studies specifically examine the largest growing HIV demographic, the inner-city HIV population.
Methods: Patient's HIV and cancer clinical, laboratory, and survival data were compiled from the CHAMP database. Psychiatric hx and social factors including drug use and time of HIV dx were also analyzed by retrospective chart review and compared between racial and gender groups as well as differences and overall survival (OS). Survival data was examined using Kaplan-Meier analysis and Cox Proportional Hazards model. Statistical comparisons between different groups were performed via the Fisher's exact test.
Results: Between 1995-2018, 226 lymphoma pts were identified spanning 26 diagnoses. Fifty-nine percent, 28%, and 11% were African American (AA), Hispanic, and Caucasian, respectively. The cohort was 87% male. The median age by disease ranged from 35-45. Categorized by cancer type; 32% were diffuse large B-cell lymphoma (DLBCL; n=72), 22.5% classic Hodgkin lymphoma (cHL; n=32), 13% Burkitt lymphoma (BL; n=29), 6.7% primary CNS lymphoma (PCNSL; n=15), and 5% plasmablastic lymphoma (PBL; n=11). Seventy-eight percent of pts presented with stage III/IV disease. CD4+ T cell count (CD4) at dx varied by disease, with the median CD4 count ranging from 19 for PCNSL to 260 cells/µL in cHL. DLBCL pts treated with DAEPOCHR (n=23) had a 5-year OS of 80% vs. 68% treated with CHOPR (n=35; p=0.4). cHL had a 5-year OS of 76%. PBL and BL had a 10-year OS of 62% and 58%, respectively. Cases of cHL decreased from 48% of all lymphomas in 2012 (n=8) to 9% in 2017 (p<0.01) while the incidence of BL dropped from 38% in 2004 to 0-10% in 2015-2017. PBL was diagnosed only twice before 2013 to on average of 20% of all lymphomas diagnosed from 2014-17. As a whole, 22% of pts were diagnosed with HIV/AIDS at time of lymphoma dx. Moreover, 13/21 (62%) of Hispanics, 9/41 (22%) AA and 3/11 (30%) Caucasians (p<0.007) with DLBCL and 5/6 (83%) Hispanic vs. 3/18 (18%) AA pts with BL were diagnosed with HIV/AIDS at dx (P<0.007). While Hispanics with DLBCL were more likely to be diagnosed with HIV at lymphoma dx, there was no difference in OS at 5 years, 76% vs. 75%, when stratified by those presenting with compared to those without a known hx of HIV infection. Furthermore, 11/43 (26%) AA DLBCL pts had a hx or known psychiatric disorder compared to 0/20 (0%) Hispanic pts (p<0.037). Men 26/59 (44%) vs. 8/10 (80%) women DLBCL pts had hx of known drug use (p=0.036). No difference in OS by drug use, type of drug, alcohol use, or psychiatric hx was identified in the DLBCL cohort.
Conclusions: HIV/AIDS-associated lymphoma in the inner-city remains an AA, male dominated disease, a clear disparity compared to the US HIV/cancer population. Dissimilar to national trends, a statistical decrease in cases of cHL and BL has been noticed over time with a concomitant elevation in PBL. Outcomes for DLBCL were improved with DAEPOCHR compared to CHOPR. Wh en analyzed by race, the majority of Hispanics with lymphoma were diagnosed with HIV at the time of dx, statistically significant, over AA and Caucasians. AA also demonstrated a statistically significant increase in psychiatric hx compared to other races. These findings could explain why 78% of our lymphoma cohort present with advanced stage disease. Combining efforts in prevention/screening of HIV and drug use and providing psychological interventions could help improve outcomes for Hispanics and AA beyond that made with improved therapies.

Disclosures
No relevant conflicts of interest to declare.