Medical News

Physicians in the U.S. are reporting a higher risk for certain types of cancers — such as liver, head, neck and lung — in people living with HIV/AIDS, raising concerns that a cancer epidemic is imminent in the population, the Baltimore Sun reports. According to the Sun, Meredith Shiels, a doctoral candidate at the Johns Hopkins Bloomberg School of Public Health, presented a paper on Tuesday at the seventh annual American Association for Cancer Research International Conference on Frontiers in Cancer Prevention Research that said people living with HIV are twice as likely as the general population to develop cancers not previously linked with the virus. Other studies have found that people living with HIV have as much as a 10 times greater chance of developing certain cancers compared with the general population. William Blattner, an associate director of the University of Maryland Institute of Human Virology, said researchers are “really at the first stages of systematically looking at the epidemic and fully looking at cancer.” He added that “[b]efore, you died from AIDS, so you didn’t have time to develop cancer. … The unusual observation is the cancers are occurring at a much younger age.”

Although researchers do not know the exact reasons for the increased risk of developing some cancers, there are several theories as to why HIV-positive people are more susceptible, such as the increased life expectancy due to antiretroviral drugs; weakened immune systems related to the virus or the effects of antiretrovirals; and the likelihood of increased high-risk behaviors in people living with HIV. The Sun reports that a well-known researcher “wonders” if antiretrovirals could be a carcinogen. In addition, many cancers found in people living with HIV are known to be caused by viruses, such as anal, head, neck and cervical cancers — which have been linked to the human papillomavirus — and liver cancer, which has been linked to hepatitis. Mark Wainberg, director of the McGill University AIDS Center in Montreal, said, “There’s a real concern about all these cancers and what they portend. Obviously, we don’t want an epidemic of cancers in long-term HIV-infected people.”

According to the Sun, physicians have discovered that treatments for cancer do not work as well in patients who have compromised immune systems, and some researchers have suggested that cancer develops regularly in all people but the immune system is able “to keep most of them in check.” A person living with HIV may not have an immune system that is able to do this as effectively, the Sun reports. However, people with HIV who develop cancer do not “always have the weakest immune systems, further confounding researchers,” according to the Sun. Eric Engels, a researcher at the National Cancer Institute studying HIV/AIDS and lung cancer, said research into how the immune system and cancer interact could provide a wider application than just helping people living with HIV. “This research has implications for people who have a healthy immune system, too,” he said.

The Sun also reports that cases of lung cancer among people living with HIV are increasing, and a 2003 study conducted by Johns Hopkins thoracic surgeon Malcolm Brock found 80 cases of HIV-positive lung cancer patients out of a total 12,000 lung cancer patients who received treatment at Johns Hopkins Hospital dating back to 1950. Brock said people living with HIV have a three to five times higher risk of developing lung cancer than the general population, with a high risk even when controlled for smoking. He also said the median age of lung cancer patients who are living with HIV is 46, compared with 64 among the general population. “The deaths here were overwhelmingly cancer-related. They were not due to AIDS,” Brock said, adding that “these patients die and they die quickly,” with an average period of six years between HIV diagnosis and lung cancer diagnosis. Engels said that although the cancer is not caused by a virus, it could be the result of an unknown infection, scarring of the lungs or some type of inflammation, which could explain why it is increasingly being found in people living with HIV.

Shiels said that the trend in cancer development in HIV-positive people might have been detected earlier if antiretrovirals were developed sooner. “Perhaps if they had lived longer, we would have seen this 10 years ago,” she said. Kevin Cullen, director of the University of Maryland Greenebaum Cancer Center, said that 10 or 20 years ago “virtually no one [living with HIV] who developed cancer could survive rigorous cancer treatment,” but antiretrovirals have allowed people to successfully undergo cancer treatment.

Wainberg said that recent gains in HIV/AIDS treatment have given some people who are at high risk for contracting the virus a false sense of security. “There is no doubt that there are people among vulnerable groups who now have a bit of an attitude of … ‘If I get HIV, the drugs are going to help me anyway,’” he said, adding that high-risk groups need to know about the risks of cancers associated with HIV. Engels said that recent findings involving an increased risk of cancer among people living with HIV should not reduce the developments in HIV/AIDS treatment in the U.S. He said, “If you had to pick a time and a place to live with HIV infection, America today would be the best time and place we’ve ever had. But we’re finding these problems coming to the surface that we didn’t see before” (Desmon, Baltimore Sun, 11/19).
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The Wall Street Journal on Tuesday examined how China is increasingly promoting condoms as a method of HIV prevention. While HIV “has long thrived quietly on the fringes of Chinese society” among injection drug users and tainted blood recipients, there is now a risk of HIV spreading further into the general population. One reason is the “booming ” sex work industry in China which “has helped make sex the most common form of” HIV transmission in the country, according to the Journal. This has given rise to increased promotion of condom use to prevent HIV from spreading. A recent survey by UNAIDS conducted in six major cities in China found that 54% of respondents said they would use a condom when having sex with a new partner

China’s “hopes of stopping the disease from turning into the country’s next health crisis may rest with the efforts of people like Guan Baoying,” who has “defied standard government attitudes about high-risk groups” such as sex workers, the Journal reports. Guan first encountered HIV/AIDS in the mid-1980s when she worked at Beijing’s Center for Disease Control. She then began visiting detention centers in Beijing that held sex workers to educate women about HIV/AIDS prevention. According to the Journal, “[t]ens of thousands of massage parlors and karaoke bars double as brothels, where businessmen and migrant workers can contract the disease and carry it to their hometowns and families.” Sex workers are “disadvantaged people in society,” Guan said, adding, “No one cares about them.”

In 2004, Guan garnered support from 12 government departments for a regulation that aimed to increase condom access in Beijing. In March 2006, a regulation issued by the State Council required government-designated public places, including hotels, to install condom vending machines or provide access to condoms through another method. Beijing in May 2008 began requiring that condoms be placed in all public places, such as restrooms, karaoke bars and large construction sites. “It is by no means easy for Beijing to take this step, and I am very happy to see it happen finally,” Guan said.

Guan in 2007 retired as the head of disease control at the Beijing Municipal Health Bureau and now works for the Beijing office of the HIV/AIDS program of the Global Fund To Fight AIDS, Tuberculosis and Malaria. Although many parts of China have not adopted her approach to HIV/AIDS prevention, the Bill & Melinda Gates Foundation in 2007 adopted Guan’s prevention and outreach model and began replicating it in 12 provinces. “We have done our best to make people aware of the importance of wearing condoms, but it’s hard to judge how many of them will actually do it,” she said (Zamiska/Fowler, Wall Street Journal, 11/18).
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The International Criminal Police Organization recently confiscated $6.65 million worth of counterfeit HIV/AIDS, malaria and tuberculosis drugs in Southeast Asia and made 27 arrests as part of a five-month investigation involving nearly 200 raids, Aline Plancon, an officer involved in the operation, said on Monday, Bloomberg reports. During the investigation, called Operation Storm, authorities seized more than 16 million pills between April 15 and Sept. 15 in Cambodia, China, Laos, Myanmar, Singapore, Thailand and Vietnam. The operation was a joint effort between Interpol, the World Health Organization and the World Customs Organization. It was the first time customs officials, drug regulators, health authorities and police from different countries have collaborated to prevent the distribution of counterfeit medicines, Plancon said.

According to Bloomberg, health officials particularly are concerned about fake artemisinin-based combination therapies used to treat malaria. According to a recent study, counterfeit ACTs containing insufficient amounts of artemisinin are contributing to the development of drug-resistant parasites near the border of Cambodia and Thailand. The rise in drug resistance has reduced the effectiveness of genuine ACTs, thus placing more people at risk for developing drug-resistant malaria, Bloomberg reports.

According to WHO and the Center for Medicine in the Public Interest, worldwide sales of counterfeit drugs could reach $75 billion by 2010, an increase of more than 90% since 2005. An Organization for Economic Cooperation and Development report released last year identified Asia as the largest producer of counterfeit products worldwide. Of the 1,047 arrests made in 2007 related to counterfeit medicine, about 40% took place in Asia, the Pharmaceutical Security Institute reports (Bennett, Bloomberg, 11/17).

Related Opinion Piece
The seizure by Belgian authorities in September of more than two million fake malaria drugs and painkillers manufactured in India for African distribution “shines a light on one of the most pressing problems in delivering life-saving medicines to the world’s poorest patients: the proliferation of low-quality and counterfeit products,” Roger Bate, a director of Africa Fighting Malaria and fellow at the American Enterprise Institute, writes in a New York Times opinion piece. He adds, “If aid organizations are serious about combating the spread of deadly diseases in the developing world, they must do more to ensure the safety and quality of drugs.”

Although WHO reports that about 30% of the world’s population lacks essential medicines, “this problem cannot be solved by supplying bogus medicines,” Bate writes. According to Bate, insufficient access to drugs has led many governments in developing countries to allow local drug makers to produce cheaper medicines. However, “local producers often make low-quality drugs,” he writes, adding that this should be “no surprise” because “[e]ven countries with stringent regulatory systems sometimes turn up bad pharmaceuticals.” According to Bate, many developing countries “lack the regulatory structure needed to monitor safety and effectiveness,” do not have “laws against selling sub-standard drugs” and lack “sophisticated agencies like the FDA with the trained inspectors and laboratories needed to analyze pharmaceuticals.”

According to Bate, it is “essential” for these countries to enact regulations, establish monitoring agencies and build scientific capacity to oversee drug manufacturing and inspect imported and local drugs. Bate also identifies three ways that international aid organizations can help ensure drug quality: providing financial and technical support; refusing to subsidize low-quality drugs; and insisting that only medicines approved by “stringent drug agencies like the FDA” be distributed. Bates writes, “If aid organizations are serious about combating the spread of deadly diseases in the developing world, they must do more to ensure the safety and quality of drugs.” He concludes, “Thousands of lives depend on their efforts” (Bate, New York Times, 11/15).
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