French researchers analysed data from medical records contained in a database on over 80,000 HIV positive subjects collected since 1989 from 69 hospitals. They also reviewed medical records on AIDS-related lymphoma from three major AIDS treatment centres in Paris — Hôpital Rothschild, CHU Pitié Salpêtrière and Hôpital de l'Institut Pasteur.
The researchers compared data from a period before HAART was available (1993-1994) against that from a period when HAART was in use (1997-1998). On the whole they found that the proportion of PHAs developing systemic lymphoma fell by 50% in the more recent era. When the researchers looked specifically at the data on brain lymphoma, they found that this condition was three times less common in the more recent era.
Despite these apparently favourable changes the researchers also found that the risk of developing both types of lymphoma among people with similar CD4+ counts had not changed in the more recent period. For instance, in the pre-HAART years, people who had 350 or more CD4+ cells had almost the same risk of developing lymphoma as people with similar cell counts in the more recent time. There was a similar trend for other CD4+ count ranges (for example, between 100 and 200 cells). Not surprisingly, in both periods, the proportion of PHAs with lymphoma increased as the CD4+ cell count fell.
Results from subjects in the three Parisian hospitals were similar to those seen from the large database. The researchers found that the proportion of PHAs with lymphoma in the brain in the more recent period decreased compared to the earlier time.
In general, the research team found that subjects in the more recent time tended to have higher CD4+ counts than subjects in the time before HAART. Since lymphoma is most common in people with very low CD4+ counts — fewer than 50 cells — and most people in the recent era had higher CD4+ cell counts, the proportion of people with lymphoma was decreased compared to the pre-HAART era. Indeed, lymphoma rates among people with fewer than 200 CD4+ cells fell from about 50% in the pre-HAART era to 24% in the years HAART was available.
Other evidence for the immunologic impact of HAART is the change in length of survival after a diagnosis of lymphoma. In the time before HAART, survival after lymphoma diagnosis averaged about six months. Since HAART became available, the average survival has increased nearly three times to about 20 months. Because the treatment of lymphoma has not greatly changed in the past decade this increase in survival is likely due to the effects of HAART. So as long as PHAs can continue to maintain high CD4+ counts, lymphoma rates should continue to fall. However, PHAs' risk of developing this cancer will not go away because HAART is only able to partially repair the damage wrought by years of HIV infection. More research on better, less toxic anti-cancer therapies, immune boosters and tests to predict which PHAs are at high risk of developing lymphoma are urgently needed.
REFERENCES
1. Besson C, Goubar A, Gabarre J, et al. Changes in AIDS-related lymphoma since the era of highly active antiretroviral therapy. Blood 2001;98(8):2339-2344.
2. Smith KA. To cure chronic HIV infection, a new therapeutic strategy is needed. Current Opinion in Immunology 2001;13(5):617_24.
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