HIV/AIDS Comorbidities: Impact on Cancer, Noncommunicable Diseases, and Reproductive Health

The total number of people living with human immunodeficiency virus (HIV) worldwide continues to grow annually, attributable to both new infections and the increased longevity of infected persons treated with potent antiretroviral therapy (ART). This growing population bears the burden of associated health conditions that complicate long-term HIV infection. Specifically, secondary epidemics of cancer; reproductive ill health; and noncommunicable diseases, such as cardiovascular disease, diabetes, renal dysfunction, and liver damage, have been observed across the globe. This wide spectrum of illnesses complicating ongoing HIV infection is a challenging global health threat and underscores the need for a greater understanding of these comorbidities, broader access to treatment, and increasingly sophisticated treatment to avoid widespread preventable morbidity and death. This chapter provides an overview of some of the most common, most rapidly increasing, or most morbid complications of persistent HIV infection; it is not meant to be exhaustive. Additionally, many comorbidities of long-term HIV infection are addressed in detail in other chapters of this volume. The first portrayals of the epidemic in the early 1980s in the United States described a surge of cancer cases among men who have sex with men (MSM). Since the initial reports from the early epidemic, it has become clear that HIV threatens the reproductive health of women across income settings and populations. Paradoxically, in an age of new hope for prolonged lifespan stemming from the success of ART, increased longevity is also bringing a host of noncommunicable chronic comorbidities (NCCs). Among cancers—the focus of the first section of this chapter—the pandemic initially saw an annual rise through 1996 in what came to be known as acquired immune deficiency syndrome (AIDS)–defining cancers (ADCs), including Kaposi sarcoma (KS), non-Hodgkin lymphoma (NHL), and cervical cancer (CDC 1992). These cancers decreased in incidence with the widespread availability of ART in high-resource settings but never fell to the levels seen before HIV; they continue with little change in incidence in low- and middle-income countries (LMICs). Additionally, a troubling rise in other, non-AIDS defining cancers (NADCs)—such as anal cancer, hepatocellular carcinoma (HCC), and lung cancer—continues to be observed globally despite access to ART. The next section of the chapter considers the multifaceted impact of HIV on women’s reproductive health. Girls and women who are at risk of HIV or who are already infected are vulnerable to problems of access to adequate reproductive choice and contraceptive options. Yet, the evidence suggests that preventing mother-to-infant transmission of HIV can effectively be achieved through the prevention of unplanned or unwanted pregnancies. Barrier contraceptive methods, although suboptimal at preventing pregnancy, do protect against HIV. The section also examines the complicated influence of HIV on infertility in women and the transmission of human papillomavirus (HPV), herpes simplex virus (HSV), pelvic inflammatory disease, bacterial vaginosis, and others. The final section of the chapter highlights the wide range of NCCs associated with long-standing HIV infection, including cardiovascular and metabolic illnesses. Taken together, the data from many parts of the world clearly show that despite the dramatic decrease in deaths due to HIV with the continued expansion of access to successful treatment, access to ART alone will not prevent, and in some cases may precipitate, a wide spectrum of complications of long-term HIV infection. These challenges require the attention of health care providers, policy makers, and researchers, empowered by access to accurate information on the burden of these diseases and the growing number of potential solutions.