HIV-associated lymphoma—advances in clinical management

The association between human immunodeficiency virus (HIV) and lymphoma was observed early in the HIV epidemic in the 1980s. Lymphoma incidence remains significantly higher than in the general population. Previously people living with HIV (PLWH) had advanced immune suppression, organ dysfunction and consequently poor performance status (PS). The advent of combination antiretroviral therapy (ART) has led to improved immune reconstitution and significantly enhanced the outlook of PLWH, influenced the incidence of lymphoma subtypes and improved tolerability of treatment. However lymphoma still remains the most common cause of cancer related death. We describe the multidisciplinary management of HIV-associated lymphomas and outline recent advances. Challenges include the advanced stage at presentation, propensity for extranodal sites including the central nervous system (CNS), potential drug interactions and increased incidence of opportunistic infections (OIs). Overall management now focusses less on HIV-related factors and more on lymphoma characteristics, with favourable outcomes. Representation in lymphoma clinical trials however is lacking, as a positive serostatus is an exclusion criterion for the majority. Data is scant for the rarer subtypes. A number of small phase I/II trials have successfully recruited patients living with HIV. Immunotherapy trial and safety data will be essential in understanding toxicity and efficacy of this promising targeted treatment. We welcome the recent more permissive inclusion criteria for clinical trials and support the expansion of understudied targeted therapies particularly for rarer subtypes. Broadening access will provide better equity for those living with HIV.