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Is Raltegravir Best for HIV-Infected Individuals Treated for Cancer? News from ICAAC 2013

In the era of effective antiretroviral therapy (ART), cancer is among the leading causes of death in HIV-infected individuals. Classical AIDS-related cancers have declined but continue to occur in patients who are untreated or incompletely treated. Rates of certain non-AIDS cancers appear to be increased in HIV. With concurrent use of ART to suppress HIV replication and improve host immune function, treatment of many cancers in HIV-infected individuals can be as effective as in HIV-negative patients. However, finding an effective ART regimen to combine with cancer chemotherapy may be challenging. Because of a favorable safety and tolerability profile, and freedom from major drug-drug interactions, the integrase strand transfer inhibitor (INSTI) raltegravir is preferred by many experts to anchor ART regimens in patients receiving cancer chemotherapy. Investigators from the MD Anderson Cancer Center retrospectively reviewed their experience with ART use and outcome in 154 HIV-infected patients treated for cancer between 2001-2012. The majority had hematologic malignancies, mostly lymphoma. Outcomes were analyzed in four ART groups; 2 NRTIs plus either a protease inhibitor (n=57), an NNRTI (n=50), an INSTI (n=30), and other combinations (n=17). Viral efficacy was defined as maintaining HIV RNA <200 copies/mL, or absence of rebound to >200 after reaching <200, and was assessed after 6 months of treatment. In a multivariable analysis, the INSTI or NNRTI groups were 6 and 9 times more likely to have virologic success, respectively, than those in the PI group. Mortality, treatment interruptions and ART-related adverse events were lower in the INSTI group (13/7/3%, respectively) than either the NNRTI (36/26/14/%) or the PI (46/28/35%) group. The study has several limitations, including retrospective data collection, non-random assignment to treatment, small sample size and differences in baseline characteristics among ART groups. Because clinicians often choose ART-regimens based on patient characteristics, channeling bias may have influenced the observed outcomes. Nevertheless, this study provides support for the practice of choosing the INSTI raltegravir, to anchor ART regimens. Raltegravir was the only INSTI used during this study. Because elvitegravir and dolutegravir have different safety and drug interaction profiles, the observations in this study probably should not be extrapolated to these newer INSTIs.

1. Torres HA, Rallapalli V, Saxena A, et al. Efficacy and Safety of Antiretrovirals in HIV-Infected Patients with Cancer. 53rd ICAAC, Denver CO, Sept 10-13, 2013, Abstract H-1255.

Source: Reporting from Denver for the PRN News: David H Shepp, MD