Does the National Comprehensive Cancer Network (NCCN) recommend Human Immunodeficiency Virus (HIV) testing for all oncological patients?

NCCN Recommendations for HIV Testing in Oncological Patients

The NCCN panel strongly recommends HIV testing for all patients diagnosed with cancer who do not opt-out, and specifically emphasizes that all patients receiving chemotherapy or immunosuppressive therapy should be screened for HIV. 1

Current NCCN Guidelines on HIV Testing

• The NCCN supports the Centers for Disease Control and Prevention (CDC) recommendation for routine HIV testing in all patients in healthcare settings unless the patient declines testing (opt-out screening) 1
• HIV testing is particularly important in patients with cancer because identification of HIV infection has the potential to improve clinical outcomes 1
• The NCCN panel emphasizes that all patients receiving chemotherapy or immunosuppressive therapy should be screened for HIV 1
• HIV screening should be voluntary and conducted only with consent from patients, following an opt-out approach where patients are informed either verbally or in writing that HIV testing will be conducted unless they decline 1

Rationale for Universal HIV Testing in Cancer Patients

• An estimated 1.1 million persons are living with HIV in the United States, including approximately 166,000 persons whose infection has not yet been diagnosed 1
• Patients who are HIV-positive and have cancer may have worse outcomes compared to HIV-negative patients with the same cancer 1
• Early identification of HIV allows for:
  • Appropriate linkage to HIV care with specialists 1
  • Initiation of antiretroviral therapy, which improves survival in people living with HIV 1
  • Better cancer treatment tolerance, higher response rates, and improved survival 1
  • Prevention of opportunistic infections 1

Special Considerations for Specific Cancer Types

• HIV testing is particularly important in the context of suspected or confirmed AIDS-defining cancers 1:
  • Kaposi sarcoma (risk is approximately 500-fold higher in people living with HIV) 1
  • Non-Hodgkin lymphoma 1
  • Cervical cancer 1
• Despite the clear recommendations, implementation varies by cancer type:
  • A study at MD Anderson Cancer Center found that while 88.4% of patients with NHL were screened for HIV, only 12.1% of patients with non-AIDS-defining cancers and 9.4% of patients with cervical cancer were screened 1
• HIV seroprevalence is significantly higher in cancer patients compared to the general population, highlighting the importance of universal screening 2

Implementation of HIV Testing in Oncology Practice

• HIV testing should be performed at cancer diagnosis or before initiation of cancer therapy 1
• For patients who test positive for HIV:
  • Refer to an HIV specialist for collaborative care 1
  • Continue antiretroviral therapy during cancer treatment if already started 1
  • For newly diagnosed HIV patients, initiate antiretroviral therapy optimally 7 days before starting cancer treatment or after the first cycle of cancer therapy 1
  • Monitor HIV viral load monthly during therapy and then as clinically indicated 1
• Be aware of potential drug-drug interactions between antiretroviral therapies and cancer treatments 1

Common Pitfalls and Caveats

• Despite clear recommendations, HIV testing rates in cancer patients remain suboptimal across different cancer types 2, 3
• Failure to diagnose HIV infection can lead to:
  • Missed opportunities for appropriate antiretroviral therapy 1
  • Increased risk of opportunistic infections 1
  • Poorer cancer treatment outcomes 1
  • Potential drug-drug interactions between unrecognized HIV medications and cancer therapies 1
• Patients with HIV may require special considerations for cancer treatment, including dose adjustments and closer monitoring 1