HIV testing and burden of HIV infection in black cancer patients in Johannesburg, South Africa: a cross-sectional study

Age-specific burden of cervical cancer associated with HIV: A global analysis with a focus on sub-Saharan Africa

HIV substantially worsens human papillomavirus (HPV) carcinogenicity and contributes to an important population excess of cervical cancer, particularly in sub-Saharan Africa (SSA). We estimated HIV- and age-stratified cervical cancer burden at a country, regional and global level in 2020. Proportions of cervical cancer (a) diagnosed in women living with HIV (WLHIV), and (b) attributable to HIV, were calculated using age-specific estimates of HIV prevalence (UNAIDS) and relative risk. These proportions were validated against empirical data and applied to age-specific cervical cancer incidence (GLOBOCAN 2020). HIV was most important in SSA, where 24.9% of cervical cancers were diagnosed in WLHIV, and 20.4% were attributable to HIV (vs 1.3% and 1.1%, respectively, in the rest of the world). In all world regions, contribution of HIV to cervical cancer was far higher in younger women (as seen also in empirical series). For example, in Southern Africa, where more than half of cervical cancers were diagnosed in WLHIV, the HIV-attributable fraction decreased from 86% in women ≤34 years to only 12% in women ≥55 years. The absolute burden of HIV-attributable cervical cancer (approximately 28 000 cases globally) also shifted toward younger women: in Southern Africa, 63% of 5341 HIV-attributable cervical cancer occurred in women <45 years old, compared to only 17% of 6901 non-HIV-attributable cervical cancer. Improved quantification of cervical cancer burden by age and HIV status can inform cervical cancer prevention efforts in SSA, including prediction of the impact of WLHIV-targeted vs general population approaches to cervical screening, and impact of HIV prevention.

Patterns of HIV testing among women diagnosed with invasive cervical cancer in the New Jersey Medicaid Program

PURPOSE

Practice-based guidelines recommend HIV testing during initial invasive cervical cancer (ICC) workup. Determinants of HIV testing during diagnosis of AIDS-defining cancers in vulnerable populations, where risk for HIV infection is higher, are under-explored.

METHODS

We examine factors associated with patterns of HIV testing among Medicaid enrollees diagnosed with ICC. Using linked data from the New Jersey State Cancer Registry and New Jersey Medicaid claims and enrollment files, we evaluated HIV testing among 242 ICC cases diagnosed from 2012 to 2014 in ages 21-64 at (a) any point during Medicaid enrollment (2011-2014) and (b) during cancer workup 6 months pre ICC diagnosis to 6 months post ICC diagnosis. Logistic regression models identified factors associated with HIV testing.

RESULTS

Overall, 13% of women had a claim for HIV testing during ICC workup. Two-thirds (68%) of women did not have a claim for HIV testing (non-receipt of HIV testing) while enrolled in Medicaid. Hispanic/NH-API/Other women had lower odds of non-receipt of HIV testing compared with NH-Whites (OR: 0.40; 95% CI: 0.17-0.94). Higher odds of non-receipt of HIV testing were observed among cases with no STI testing (OR: 4.92; 95% CI 2.27-10.67) and < 1 year of Medicaid enrollment (OR: 3.07; 95% CI 1.14- 8.26) after adjusting for other factors.

CONCLUSIONS

Few women had HIV testing claims during ICC workup. Opportunities for optimal ICC care are informed by knowledge of HIV status. Further research should explore if lack of HIV testing claims during ICC workup is an accurate indicator of ICC care, and if so, to assess testing barriers during workup.

Molecular characterization of hepatitis B virus isolated from Black South African cancer patients, with and without hepatocellular carcinoma

In South Africa (SA), hepatitis B virus (HBV) infection is strongly associated with hepatocellular carcinoma (HCC). As HBV genotypes/subgenotypes and mutations can influence disease manifestation and progression, our aim was to molecularly characterize HBV in Black cancer patients, with and without HCC. The basal core promoter/precore (BCP/PC) and complete surface (S) regions of HBV isolates were amplified and sequenced from 55 HCC cases and 22 non-HCC cancer controls. Phylogenetic analysis of 43 polymerase/complete S region amplicons showed that the majority (88.4%) clustered with subgenotype A1, 4.7% with A2, and 7% with A3. The following mutations were significantly more frequent in HCC cases than in controls (p < 0.05): in the BCP/PC 1753C/G (22.5% vs. 0%), 1764A (69.4% vs. 38.1%), and T64C (51.5% vs. 20%) in the preS2, which results in a F22L substitution. PreS1 and preS2 start codon mutants were detected only in HCC cases, occurring in two and 16 isolates, respectively. PreS deletion mutants were isolated from 11 HCC cases, which had a HBV viral load > 10,000 IU/mL and were significantly younger than non-HCC controls (34 ± 7.1 vs. 41.2 ± 9.5 years, p = 0.05). The 1762T/1764A double mutation was detected in the majority (90.9%) of the isolates from HCC cases with preS deletions. Black HBV carriers were mainly infected with subgenotype A1, with HCC cases carrying BCP/PC and preS mutant strains that are associated with hepatocarcinogenesis. This is the first study to compare the molecular characteristics of HBV from HCC and non-HCC cancer patients in SA.

Johannesburg Cancer Study (JCS): contribution to knowledge and opportunities arising from 20 years of data collection in an African setting

The Johannesburg Cancer Study (JCS) aims were to examine whether cancer risk factors identified in Western countries applied to black patients in Johannesburg, South Africa and to understand the impact of HIV on cancer risk, with a view to identifying previously unrecognised HIV associated cancers. A total of 24 971 black patients with an incident histologically proven (>95%) cancer of any type were enrolled between 1995-2016. Response rates were >90%. Patients provided informed consent, lifestyle and demographic information using a structured questionnaire; 19 351 provided a serum sample and 18 972 a whole blood sample for genomic analyses. This is currently the largest cancer epidemiological biobank in Africa. JCS uses a cancer case-control method; controls being cancer types unrelated to exposures of interest. Published results show the importance of HIV in several cancers known to be infection associated e.g. Kaposi sarcoma (OR = 1683; CI = 595-5194) in those with high Kaposi-sarcoma-associated-herpesvirus titres; no effect of HIV on lung or liver cancer-in the latter showing a strong association with HBVDNA, sAg and c positivity (OR = 47; CI = 21-104). Comparable data to higher-income country studies include lung cancer ORs in relation to smoking (15+g tobacco/day) (OR_Males = 37; CI = 21-67, OR_Females = 18.5; CI = 8-45) and associations between alcohol and oesophageal cancer in smokers (OR_M&F = 4.4; CI = 3-6). Relationship between hormonal contraception declined to null 10 or more years after stopping for breast (OR = 1.1; CI = 0.9-1.4) and cervical cancer (OR = 1.0;CI = 0.8-1.2), and protective effects shown, five or more years after stopping for ovarian (OR = 0.6; CI = 0.4-1) and endometrial cancer (OR = 0.4; CI = 0.2-0.9). Preferential access is based on data requests promoting data pooling, equal collaborative opportunities and enhancement of research capacity in South Africa. The JCS is a practical and valid design in otherwise logistically difficult settings.

The burden of cancers associated with HIV in the South African public health sector, 2004-2014: a record linkage study

Introduction

The impact of South Africa’s high human immunodeficiency virus (HIV) burden on cancer risk is not fully understood, particularly in the context of antiretroviral treatment (ART) availability. We examined national cancer trends and excess cancer risk in people living with HIV (PLHIV) compared to those who are HIV-negative.

Methods

We used probabilistic record linkage to match cancer records provided by the National Cancer Registry to HIV data provided by the National Health Laboratory Service (NHLS). We also used text search of specific HIV terms from the clinical section of pathology reports to determine HIV status of cancer patients. We used logistic and Joinpoint regression models to evaluate the risk and trends in cancers in PLHIV compared to HIV-negative patients from 2004 to 2014. In sensitivity analysis, we used inverse probability weighting (IPW) to correct for possible selection bias.

Results

A total of 329,208 cancer cases from public sector laboratories were reported to the NCR from 2004 to 2014 with the HIV status known for 95,279 (28.9%) cancer cases. About 50% of all the female cancer cases (n = 30,486) with a known status were HIV-positive. PLHIV were at higher risk of AIDS-defining cancers (Kaposi sarcoma [adjusted OR:134, 95% CI:111–162], non-Hodgkin lymphoma [adjusted OR:2.73, 95% CI:2.56–2.91] and, cervix [adjusted OR:1.70, 95% CI:1.63–1.77], conjunctival cancer [adjusted OR:21.5, 95% CI:16.3–28.4] and human papilloma virus (HPV) related cancers (including; penis [adjusted OR:2.35, 95% CI:1.85–2.99], and vulva [adjusted OR:1.94, 95% CI:1.67–2.25]) compared to HIV-negative patients. Analysis using the IPW population yielded comparable results.

Conclusion

There is need for improved awareness and screening of conjunctival cancer and HPV-associated cancers at HIV care centres. Further research and discussion is warranted on inclusive HPV vaccination in PLHIV.

Human immunodeficiency virus infection in breast cancer patients: The prevalence thereof and its effect on breast cancer characteristics at Dr. George Mukhari Academic Hospital Breast Clinic, Ga-Rankuwa, South Africa

BACKGROUND

Since the advent of highly active anti-retroviral therapy, improved immune functioning and prolonged survival of Human immunodeficiency virus (HIV)-positive patients has been accompanied by an increased incidence of non-AIDS-defining cancers (NADC). Breast cancer is the most prevalent NADC among HIV-positive women. However, data regarding the interaction between these two diagnoses remain limited.

OBJECTIVES

To determine the effect of HIV status on the presentation of breast cancer patients at Dr. George Mukhari Academic Hospital (DGMAH).

METHODS

The age, gender, HIV status, CD4 count and tumour node metastases stage at presentation were recorded from the files of patients with histologically proven breast carcinoma, who had presented to the breast clinic at DGMAH from 01 January 2013 to 30 November 2017. Histological subtypes and molecular markers were retrieved from the National Health Laboratory Service. Prevalence of HIV among breast cancer patients was calculated. Cross-tabulations compared the variables between HIV-positive and HIV-negative groups. Statistical significance was assessed using Fisher's Exact Test.

RESULTS

HIV status was determined in 129 breast cancer patients. Eighty (62.02%) were HIV-negative and 49 (37.98%) were HIV-positive. All patients were female. The mean age at presentation with breast cancer in the HIV-positive group was approximately 10 years younger, compared to the entire population and to the HIV-negative group (p < 0.0001). No further statistically significant associations were observed concerning HIV status and other variables.

CONCLUSION

HIV-positive women present with breast cancer at a significantly younger mean age. Breast cancer screening protocols may need to be adjusted accordingly in such patients.

Analysis of risk factors associated with hepatocellular carcinoma in black South Africans: 2000-2012

OBJECTIVE

The aims of this study were to determine the prevalence of risk factors associated with hepatocellular carcinoma (HCC) in black adult South Africans and to estimate the size of the associated risks.

METHODS

A case-control analysis of 150 black South African patients (aged 18-75 years) with HCC-who were a subset of patients recruited for the Johannesburg Cancer Case Control Study 2000 to 2012-was undertaken. The association between this tumour and hepatitis B/C virus infections, and human immunodeficiency virus (HIV) mono- and co-infections was investigated. Odds ratios (ORs) and 95% confidence intervals (CI) adjusted for age, year of diagnosis, marital status, place of birth and selected modifiable risk factors were calculated.

RESULTS

HCC was significantly associated with a rural birthplace (p<0.05), being male and living in an urban area for 14 years or less. The Odds Ratio (OR) for HCC increased significantly with HBV DNA+/HBsAg+ (OR 34.5; CI:16.26-73.13), HBV DNA+/HBsAg- (OR 3.76; CI:1.79-7.92), HBV DNA level >2000 IU/ml (OR 8.55; CI:3.00-24.54) to ≥200,000 (OR 16.93; CI:8.65-33.13), anti-HCV (OR 8.98; CI:3.59-22.46), HBV DNA+/HIV+ co-infection (OR 5.36; CI:2.59-11.11), but not with HBV DNA-/HIV+ (OR 0.34; CI:0.14-0.85). We did not find a synergistic interaction between HBV and HIV. Modifiable risk factors (alcohol consumption, tobacco smoking, number of sexual partners, diabetes and hormonal contraceptive use) were nonsignificant.

DISCUSSION

A considerable portion of the HCC burden in Johannesburg and surrounding provinces falls on rural migrants to urban areas, most of whom are men. The HBV will continue to contribute to HCC incidence in older age-groups and in others who missed vaccination. Although we did not find an increased risk for HCC in HIV positive individuals this may change as life expectancy increases due to greater access to antiretroviral therapies, necessitating the addition of hepatitis virus screening to preventive medical care.

Investigating Barriers in HIV-Testing Oncology Patients: The IBITOP Study, Phase I

BACKGROUND

Although the prevalence of non-AIDS-defining cancers (non-ADCs) among people living with HIV is rising, we observed HIV testing rates below 5% at our oncology center, against a regional HIV prevalence of 0.2%-0.4%. We performed the Investigating Barriers in HIV-Testing Oncology Patients (IBITOP) study among oncology physicians and patients.

METHODS

Between July 1 and October 31, 2013, patients of unknown HIV status newly diagnosed with solid-organ non-ADCs referred to Lausanne University Hospital Oncology Service, Switzerland, were offered free HIV testing as part of their oncology work-up. The primary endpoints were (a) physician willingness to offer and patient acceptance of HIV testing and (b) physicians' reasons for not offering testing.

RESULTS

Of 239 patients of unknown HIV status with a new non-ADC diagnosis, 43 (18%) were offered HIV testing, of whom 4 declined (acceptance rate: 39 of 43; 91%). Except for 21 patients tested prior to oncology consultation, 175 patients (of 239; 73%) were not offered testing. Testing rate declined among patients who were >70 years old (12% versus 30%; p = .04); no non-European patients were tested. Physicians gave reasons for not testing in 16% of cases, the main reason being patient follow-up elsewhere (10 patients; 5.7%). HIV testing during the IBITOP study increased the HIV testing rate to 18%.

CONCLUSION

Although the IBITOP study increased HIV testing rates, most patients were not tested. Testing was low or nonexistent among individuals at risk of late HIV presentation (older patients and migrants). Barriers to testing appear to be physician-led, because patient acceptance of testing offered was very high (91%). In November 2013, the Swiss HIV testing recommendations were updated to propose testing in cancer patients. Phase II of the IBITOP study is examining the effect of these recommendations on HIV testing rates and focusing on physician-led testing barriers.

IMPLICATIONS FOR PRACTICE

Patients of unknown HIV status newly diagnosed with solid-organ non-AIDS-defining cancers were offered free HIV testing. Physician and patient barriers to HIV testing were examined. Most patients (82%) were not offered testing, and testing of individuals at risk of late HIV presentation (older patients and migrants) was low or nonexistent. Conversely, patient acceptance of testing offered was very high (91%), suggesting that testing barriers in this setting are physician-led. Since this study, the Swiss HIV testing recommendations now advise testing cancer patients before chemotherapy. Phase II of the Investigating Barriers in HIV-Testing Oncology Patients study is examining the effect of these recommendations on testing rates and physician barriers.