Excess cancer prevalence in men with HIV: A nationwide analysis of Medicaid data

Social needs and hospital readmission in persons living with HIV

Health-related social needs (HRSN) significantly influence healthcare utilization and outcomes. While prior studies have shown higher rates of hospital readmissions among individuals with HRSN, the impact of HRSN on hospital readmissions in persons living with HIV (PLWH) at population level, using ICD10 codes for HRSN in hospital discharge data, has not been fully explored. In this retrospective study using the 2016-2019 Florida and Maryland State Inpatient Database (SID), we examined the prevalence of HRSN among hospitalized PLWH using ICD-10 diagnosis codes including the domains of employment, family, housing, psychosocial, and education. In addition to descriptive analysis, we used multivariable logistic regression models to evaluate the association between hospital readmission and the presence of HRSN, controlling for potential confounders. In Florida, we identified 43,229 PLWH patients, of whom 9.6% (4,153) had HRSN. PLWH with HRSN had a significantly higher 90-day (40.6% vs. 23.1%) and one-year (73.6% vs. 41.3%) readmission rates compared with those without HRSN. Multivariable regression analysis showed that patients with HRSN had nearly three times the odds of 90-day readmission [adjusted odds ratio (aOR): 2.80 (95% confidence interval (CI): 2.61-3.01)] and four times the odds of one-year readmission [aOR: 3.93(95% CI: 3.62-4.27)]. In the Maryland SID, 12.5% (1,551) of the 12,396 PLWH had HRSN. PLWH with documented HRSN had a significantly higher 90-day (39.9% vs. 20.4%) and one-year (68.2% vs. 37.9%) readmission rates than those without HRSN. In multivariable regression analysis, HRSN were similarly associated with substantially higher odds of 90-day readmission [aOR: 2.70(95% CI: 2.38-3.05)] and one-year readmission [aOR: 3.60(95% CI: 3.15-4.12)]. In both states, there was a dose-response relationship between the number of HRSN and readmission rates. In conclusion, the prevalence of HRSN is associated with significantly higher rates of hospital readmissions among PLWH. Our findings highlight the importance of accounting for social factors when studying hospital readmissions and call for the development of interventions targeting HRSN to reduce readmissions in PLWH.

Early Detection of Cancer and Precancerous Lesions in Persons With HIV Through a Comprehensive Cancer Screening Protocol

BACKGROUND

Non-AIDS defining malignancies present a growing challenge for persons with human immunodeficiency virus (HIV, PWH), yet tailored interventions for timely cancer diagnosis are lacking. The Spanish IMPAC-Neo protocol was designed to compare two comprehensive cancer screening strategies integrated into routine HIV care. This study reports baseline data on the prevalence and types of precancerous lesions and early-stage cancer among participants at enrolment. Acceptability of the procedure was additionally assessed.

METHODS

Cross-sectional analysis of a comprehensive screening protocol to detect precancer and cancer. The readiness of healthcare providers to implement the protocol was evaluated using a validated 4-item survey.

RESULTS

Among the 1430 enrolled PWH, 1172 underwent 3181 screening tests, with positive findings in 29.4% of cases, leading to further investigation in 20.7%. Adherence to the protocol was 84%, with HIV providers expressing high acceptability (97.1%), appropriateness (91.4%), and feasibility (77.1%). A total of 145 lesions were identified in 109 participants, including 60 precancerous lesions in 35 patients (3.0%), 9 early-stage cancers in 9 patients (0.8%), and 76 low-risk lesions in 65 subjects (5.5%). Adverse events related to screening occurred in 0.8% of participants, all mild. The overall prevalence of cancer precursors or early-stage cancer was 3.8% (95% confidence interval [CI], 2.74%-5.01%), with highest rates observed in individuals screened for anal and colorectal cancers.

CONCLUSIONS

The baseline comprehensive cancer screening protocol of the IMPAC-Neo study successfully identified a significant proportion of PWH with precancerous lesions and early-stage cancer. High adherence rates and positive feedback from providers suggest effective implementation potential in real-world healthcare settings.

Cancer screening in people with HIV: Implementation in clinical practice and barriers perceived by medical specialists in Spain

OBJECTIVE

To assess the degree of implementation of cancer screening recommendations in people living with HIV (PLHIV) in Spain.

METHODS

A self-administered questionnaire was designed on the strategies used for early detection of the main types of cancer in PLHIV. The survey was distributed electronically to HIV physicians participating in the Spanish CoRIS cohort.

RESULTS

106 questionnaires were received from 12 different Spanish Autonomous Communities, with an overall response rate among those who accessed the questionnaire of 60.2%. The majority responded that they followed the CPGs recommendations for the early detection of liver (94.3%), cervical (93.2%) and breast (85.8%) cancers. In colorectal and anal cancer, the proportion was 68.9% and 63.2%, and in prostate and lung cancer of 46.2% and 19.8%, respectively. In hospitals with a greater number of beds, a tendency to perform more cancer screening and greater participation of the Infectious Diseases/HIV Services in the screening programmes was observed. Significant differences were observed in the frequency of colorectal and anal cancer screening among the different Autonomous Communities. The most frequent reasons for not performing screening were the scarcity of material and/or human resources and not being aware of what is recommended in the CPGs.

CONCLUSIONS

There are barriers and opportunities to expand cancer screening programmes in PLHIV, especially in colorectal, anal and lung cancers. It is necessary to allocate resources for the early detection of cancer in PLHIV, but also to disseminate CPGs screening recommendations among medical specialists.

Impact of the Affordable Care Act and Medicaid Expansion Among Patients With HIV-Associated Aggressive B-Cell Non-Hodgkin Lymphomas

PURPOSE

To study the influence of the Affordable Care Act (ACA) policy and its Medicaid expansion on insurance status and survival in patients with HIV with aggressive lymphoma.

METHODS

We used the National Cancer Database, a hospital-based national registry, to identify adults age 18-64 years with HIV-associated aggressive B-cell non-Hodgkin lymphomas (HIV-a-B-NHLs), diagnosed during 2007 to 2016. Survival analysis was performed on a subset of patients with HIV-a-B-NHL for whom location data were available who resided in Medicaid expansion-adopted and nonadopted states. Using a quasi-experimental difference-in-difference model, the difference in adjusted 2-year survival rates obtained with a flexible parametric Weibull model was compared for states that adopted the Medicaid expansion of ACA against those that did not adopt the expansion.

RESULTS

We identified 8,231 patients with HIV-a-B-NHL and 50,650 non-HIV patients with a-B-NHL. We found that a lower proportion of individuals were uninsured at diagnosis in the expansion states compared with nonexpansion states. We also found that the ACA policy adoption led to a reduction in the proportion of uninsured individuals with HIV-a-B-NHL in expansion states of 34.9%, compared with 15.9% in non-expansion-adopted states. There was a statistically significant improvement in the 2-year survival rate among patients with HIV-a-B-NHL in the expansion compared with nonexpansion states with the adoption of ACA (7.17% v 1.58%, P = .02).

CONCLUSION

Using a novel quasi-experimental model, we found that the ACA policy corresponded with a greater survival improvement in patients with HIV-a-B-NHL within Medicaid expansion-adopted states compared with nonexpansion states. We believe that this evidence should be taken into consideration in future policy making.

The microbiome as a biomarker of anal precancerous lesions in people with HIV

PURPOSE OF REVIEW

Early detection and treatment of human papillomavirus (HPV)-related anal dysplasia in some high-risk groups can help anal cancer prevention, but new tools to improve diagnostic and risk assessment are needed. Here, we aim to discuss the evidence on the role of the microbiome as a potential biomarker for anal high-grade squamous intraepithelial lesions (HSILs) in people with HIV (PWH).

RECENT FINDINGS

This review covers relevant studies on the links between the microbiome and HPV infection, cervical dysplasia/cancer, and anal HPV disease. It focuses on anal samples and precancerous lesions.

SUMMARY

The review highlights the promising potential of the anal microbiome as a novel biomarker for precancerous lesions in people with HIV, while also discussing limitations and future research needs.

Cancer screening in people living with HIV

BACKGROUND

Cancer is the leading cause of mortality in people living with HIV (PWH) and is expected to account for a growing fraction of deaths as PWH age.

METHODS

In this literature review, we have compiled the most recent developments in cancer screening and screening performance in PWH, which are currently primarily implemented in well-resourced settings. This includes an assessment of the associated benefits, harms, and cost-effectiveness. The article also addresses unmet needs and potential strategies for tailored screening in the HIV population.

FINDINGS

Incidence and mortality due to screenable cancer are higher in PWH than in the general population, and diagnosis is frequently made at younger ages and/or at more advanced stages, the latter amenable to improved screening. Adequate evidence on the benefits of screening is lacking for most cancers in the HIV population, in whom standard practice may be suboptimal. While cancer surveillance has helped reduce mortality in the general population, and interest in risk-based strategies is growing, implementation of screening programs in the HIV care settings remains low.

INTERPRETATION

Given the devastating consequences of a late diagnosis, enhancing early detection of cancer is essential for improving patient outcomes. There is an urgent need to extend the investigation in cancer screening performance to PWH, evaluating whether personalized measures according to individual risk could result in higher efficiency and improve patient outcomes.

Evaluation of the validity of the HPV viral load compared to conventional techniques for the detection of high-grade anal intraepithelial lesions in men with HIV who have sex with men

Background

The incidence of high-grade anal intraepithelial lesions (HSILs) has increased in recent years among men who have sex with men with human immunodeficiency virus (HIV). This work evaluated the validity of the human papilloma virus viral load (HPV-VL) versus cytological and qualitative HPV results to detect HSILs.

Methods

From May 2017 to January 2020, 93 men who have sex with men and HIV were included in an anal cancer screening program from the Infectious Diseases Unit at a tertiary-care hospital in Alicante (Spain). The gold-standard for the screening of anal HSILs is the anal biopsy using high-resolution anoscopy. The diagnostic methods compared against gold-standard were HPV-16-VL, HPV-18-VL, and HPV-16-18-VL co-testing, anal cytology, and qualitative HPV detection. The receiver operating characteristic (ROC) curve and cut-off points for HPV-VL were calculated. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen's Kappa coefficient (κ) were also calculated.

Results

The mean patient age was 44.6 ± 9.5 years. All of them received antiretroviral treatment, 96.8% had an HIV viral load of <50 copies/mL and 17.2% had a previous diagnosis of AIDS. The diagnosis of the anal biopsies were: 19.4% (n = 18) HSIL, 29.1% (n = 27) LSIL, and 51.6% (n = 48) negative. An HPV-16-VL >6.2 copies/cell was detected in the HSIL biopsy samples (p = 0.007), showing a sensitivity of 100% and a specificity of 46.2%. HPV-18-VL and HPV16-18-VL co-testing showed a sensitivity of 75% and 76.9% and a specificity of 72.7% and 61.3%, respectively. The highest PPV was 50% obtained with the cytology and HPV-18-VL. The HPV-16-VL showed a NPV of 100%, followed by 88.9% in the HPV-18-VL and 87% in the abnormal cytology. Cohen's Kappa coefficient were: HPV-18-VL (κ = 0.412), abnormal cytology (κ = 0.353) and HPV-16-VL (κ = 0.338).

Conclusions

HPV-VL testing improved the detection sensitivity but not the specificity for HSIL biopsies compared to anal cytology and the qualitative detection of HPV. In men who have sex with men and HIV the HPV-VL could be an useful tool for diagnosis of HSILs in anal cancer screening programs. Further studies will be needed to evaluate the clinical implications of HPV-VL in these programs.

Microbiome-derived cobalamin and succinyl-CoA as biomarkers for improved screening of anal cancer

Human papillomavirus can cause preinvasive, high-grade squamous intraepithelial lesions (HSILs) as precursors to cancer in the anogenital area, and the microbiome is suggested to be a contributing factor. Men who have sex with men (MSM) living with human immunodeficiency virus (HIV) have a high risk of anal cancer, but current screening strategies for HSIL detection lack specificity. Here, we investigated the anal microbiome to improve HSIL screening. We enrolled participants living with HIV, divided into a discovery (n = 167) and validation cohort (n = 46), and who were predominantly (93.9%) cisgender MSM undergoing HSIL screening with high-resolution anoscopy and anal biopsies. We identified no microbiome composition signatures associated with HSILs, but elevated levels of microbiome-encoded proteins producing succinyl coenzyme A and cobalamin were significantly associated with HSILs in both cohorts. Measurement of these candidate biomarkers alone in anal cytobrushes outperformed anal cytology as a diagnostic indicator for HSILs, increasing the sensitivity from 91.2% to 96.6%, the specificity from 34.1% to 81.8%, and reclassifying 82% of false-positive results as true negatives. We propose that these two microbiome-derived biomarkers may improve the current strategy of anal cancer screening.

Cancer burden in women with HIV on Medicaid: A nationwide analysis

BACKGROUND

Cancer is the leading cause of death in people living with HIV. In the United States, nearly 1 in 4 people living with HIV are women, more than half of whom rely on Medicaid for healthcare coverage.

OBJECTIVE

The objective of this study is to evaluate the cancer burden of women living with HIV on Medicaid.

DESIGN

We conducted a cross-sectional study of women 18-64 years of age enrolled in Medicaid during 2012, using data from Medicaid Analytic eXtract files.

METHODS

Using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes, we identified women living with HIV (n = 72,508) and women without HIV (n = 17,353,963), flagging the presence of 15 types of cancer and differentiating between AIDS-defining cancers and non-AIDS-defining cancers. We obtained adjusted prevalence ratios and 95% confidence intervals for each cancer and for all cancers combined, using multivariable log-binomial models, and additionally stratifying by age and race/ethnicity.

RESULTS

The highest adjusted prevalence ratios were observed for Kaposi's sarcoma (81.79 (95% confidence interval: 57.11-117.22)) and non-Hodgkin's lymphoma (27.69 (21.67-35.39)). The adjusted prevalence ratios for anal and cervical cancer, both of which were human papillomavirus-associated cancers, were 19.31 (17.33-21.51) and 4.20 (3.90-4.52), respectively. Among women living with HIV, the adjusted prevalence ratio for all cancer types combined was about two-fold higher (1.99 (1.86-2.14)) in women 45-64 years of age than in women 18-44 years of age. For non-AIDS-defining cancers but not for AIDS-defining cancers, the adjusted prevalence ratios were higher in older than in younger women. There was no significant difference in the adjusted prevalence ratios for all cancer types combined in the race/ethnicity-stratified analyses of the women living with HIV cohort. However, in cancer type-specific sub-analyses, differences in adjusted prevalence ratios between Hispanic versus non-Hispanic women were observed. For example, the adjusted prevalence ratio for Hispanic women for non-Hodgkin's lymphoma was 2.00 (1.30-3.07) and 0.73 (0.58-0.92), respectively, for breast cancer.

CONCLUSION

Compared to their counterparts without HIV, women living with HIV on Medicaid have excess prevalence of cervical and anal cancers, both of which are human papillomavirus related, as well as Kaposi's sarcoma and lymphoma. Older age is also associated with increased burden of non-AIDS-defining cancers in women living with HIV. Our findings emphasize the need for not only cancer screening among women living with HIV but also for efforts to increase human papillomavirus vaccination among all eligible individuals.