The use of immune checkpoint inhibitors in HIV, hepatitis B and C patients
- According to the current literature, immune checkpoint inhibition (ICI) in HIV patients seems to have the same efficacy and safety profile as in the general population (level of evidence II/III ;n=100 all studies confounded) (1-6, 8). Therefore, we recommend the use of ICI in HIV patients, who are under treatment with highly active anti-retroviral therapy (HAART), in the same indications as in the general population. It can only be started in HIV patients in close collaboration with an HIV specialist.
- Because of a lethal polyclonal B-cell proliferation in 1 patient who had human herpes virus 8 (HHV8) viremia (3), following patients should be treated with extreme caution:
- Patients with a history of Castleman’s disease in last 5 years
- Patients with Kaposi Sarcoma + unexplained symptoms which are suspected for Castleman’s disease should undergo assessment of HHV8 viral load as well as thoracic CT scan completed with biopsy of enlarged lymph nodes (if present) before ICI start.
- Extra precautions should be taken in patients with low CD 4 counts < 100/µL as there is less experience in this setting because less is known about these patients. Nevertheless there are a few examples in which it seems safe and efficacious (5).
- The use of ICI in chronic hepatitis B or hepatitis C infections has only been assessed in a small amount of patients. These studies show similar efficacy and safety results compared to the general population (6,7). Therefore it seems safe to start ICI in collaboration with infectiologist/hepatologist in patients with hepatitis B or C infection, especially if they are under active treatment and/or have an undetectable viral load.
Dr. Sanne De Smet, UZgent
Dr. Marie-Angélique De Scheerder, UZgent
1. Cook, Michael R., and Chul Kim. “Safety and efficacy of immune checkpoint inhibitor therapy in patients with HIV infection and advanced-stage cancer: a systematic review.” JAMA oncology 5.7 (2019): 1049-1054.
2. Spano, Jean-Philippe, et al. “Immunotherapy for cancer in people living with HIV: safety with an efficacy signal from the series in real life experience.” Aids 33.11 (2019): F13-F19.
3. Uldrick, Thomas S., et al. “Assessment of the safety of pembrolizumab in patients with HIV and advanced cancer—a phase 1 study.” JAMA oncology 5.9 (2019): 1332-1339.
4. Navarro, Alejandro, Alex Martinez-Marti, and Enriqueta Felip. “HIV-positive patients with lung cancer: is immunotherapy a safe and active option for them?.” Journal of Thoracic Oncology 13.7 (2018): 874-876.
5. Heppt, M. V., et al. “Checkpoint blockade for metastatic melanoma and Merkel cell carcinoma in HIV-positive patients.” Annals of Oncology 28.12 (2017): 3104-3106.
6. Tio, Martin, et al. “Anti-PD-1/PD-L1 immunotherapy in patients with solid organ transplant, HIV or hepatitis B/C infection.” European Journal of Cancer 104 (2018): 137-144.
7. Sangro, Bruno, et al. “A clinical trial of CTLA-4 blockade with tremelimumab in patients with hepatocellular carcinoma and chronic hepatitis C.” Journal of Hepatology 59.1 (2013): 81-88.
8. Boyer, Zoe, and Sarah Palmer. “Targeting immune checkpoint molecules to eliminate latent HIV.” Frontiers in immunology 9 (2018): 2339.