HIV and Prostate Cancer Risk
HIV-positive men have a significantly lower risk of developing prostate cancer compared to HIV-negative men, with approximately 24-50% reduced incidence, though this finding is complicated by differential screening patterns and detection bias. 1, 2
Evidence from Guidelines and Epidemiologic Data
The NCCN guidelines acknowledge that prostate cancer represents 7% of all incident cancers in people living with HIV (PLWH), making it a relevant malignancy in this population despite the overall reduced risk. 3 However, this proportion reflects the cancer distribution among those diagnosed, not the underlying incidence rate compared to HIV-negative populations.
Key Research Findings on Risk Reduction
Magnitude of Risk Reduction
A large Kaiser Permanente cohort study of 17,424 HIV-positive and 182,799 HIV-negative men found a 27% reduced prostate cancer risk in HIV-positive men (adjusted rate ratio 0.73), even after controlling for age, race, smoking, alcohol/drug abuse, obesity, and diabetes. 1
A 2021 meta-analysis of 27 studies including over 2,780 HIV-positive men with prostate cancer demonstrated a 24% decreased risk (SIR 0.76,95% CI 0.64-0.91). 2
Earlier U.S. data from the HIV/AIDS Cancer Match Study showed a 50% risk reduction during the PSA screening era (1992-2007, SIR 0.50), though this was limited to local and regional stage cancers. 4
The Screening Bias Question
The reduced prostate cancer incidence in HIV-positive men appears to be genuine and not fully explained by differential screening:
In the Kaiser Permanente Northern California subset, more HIV-positive men (90.8%) than HIV-negative men (86.2%) received PSA testing by age 55, yet HIV-positive men still had lower cancer rates. 1
When analysis was restricted only to men who had received PSA testing, the decreased risk persisted (rate ratio 0.55). 1
The risk reduction was greater for higher-stage cancers, which are less susceptible to screening detection bias. 1
However, other data suggests screening differences do play a role:
The U.S. HIV/AIDS Cancer Match Study found PSA testing was uncommon among HIV-infected men ≥40 years (only 18.7% per year), and the prostate cancer deficit was limited to the PSA era and early-stage cancers. 4
In the pre-PSA era (<1992), men with AIDS had the same prostate cancer risk as the general population (SIR 1.00). 4
Clinical Implications for Management
Screening Recommendations
HIV-positive men should receive standard prostate cancer screening according to established guidelines, with shared decision-making beginning at age 50 for average-risk men, age 45 for African American men or those with family history, and age 40 for men with multiple affected relatives. 3, 5, 6
The reduced incidence does not justify withholding screening, as HIV-positive men with well-controlled disease on HAART have similar life expectancies and cancer outcomes to HIV-negative men. 7, 8
Baseline PSA value is a stronger predictive factor than HIV status alone. 3, 6
Treatment Considerations
When prostate cancer is diagnosed in HIV-positive men, treatment should mirror that offered to HIV-negative patients:
A multi-institutional study of 17 HIV-positive men with prostate cancer found that age, PSA levels, clinical presentation, management, and outcomes were not significantly altered by HIV status in men receiving HAART. 7
All treated patients achieved complete response (undetectable PSA), with no serious treatment-related side effects. 7
Men with well-controlled HIV viremia should be managed identically to HIV-negative counterparts. 7, 8
Important Caveats
The significant heterogeneity across studies (I² = 91.6%) indicates that the relationship between HIV and prostate cancer risk may vary by population, HAART era, and screening practices. 2
African American men with HIV face dual considerations: their baseline 64% higher prostate cancer incidence and 2.3-fold higher mortality compared to white men must be weighed against the protective effect of HIV. 6
Testosterone deficiency is more common in HIV-positive men and may contribute to reduced prostate cancer risk, though adjustment for this factor still shows persistent risk reduction. 1