HIV Specialist - March 2021 - 45

BEST

PRACTICES
Impact of Delayed HIV Diagnosis on
Non-AIDS Defining Cancers
A Case Report
BY: MEGAN GAINES, PA-C, JEAN WIGGINS AND WILLIAM N. HANNAH, JR., MD

INTRODUCTION

EARLY IDENTIFICATION AND ADHERENCE to antiretroviral
therapy (ART) has generally increased the life expectancy for persons
living with HIV to the same as that of non-HIV infected persons.1 Yet,
these individuals often have substantial comorbidities that further
decrease their chances to live full and productive lives. Untreated,
HIV can lead to a weakened immune system response and Acquired
Immunodeficiency Syndrome (AIDS) in as little as eight to 10 years.2
As HIV manifests into AIDS, the risk increases for opportunistic infections and malignancies, and these diseases are often identified at an
advanced stage in the disease process. While ART regimens have led to
a decline in AIDS-defining cancers (ADC), non-AIDS defining cancers
(NADC) now represent a substantial share of morbidity and mortality
in HIV-infected individuals, especially those with late-stage AIDS.3

CASE

A 48-year old white, female presented to the emergency department
(ED) with a chief complaint of several months of recurrent perianal abscesses draining feculent material. Her past medical history
included hypertension and endometrial cancer diagnosed in 2014 for
which she underwent a hysterectomy, pelvic radiation, and vaginal
brachytherapy. During this encounter the patient declined an HIV test.

On physical examination, a digital rectal
exam revealed swelling in the left anal margin with sero-purulent drainage. Anoscopy
with biopsy showed a deep and fungating
ulceration of the left anal canal extending
approximately 3 cm proximally. The biopsy
revealed a tubulovillous adenoma with highgrade dysplasia; however, the pathologist also
noted a small focus suspicious for invasion.
An MRI of the pelvis also showed an annular
mass extending from the anal verge to the
mid rectum, which was 8.7 cm in length
and below the peritoneal reflection. The
patient was diagnosed with clinical stage IV
anorectal adenocarcinoma. She subsequently
underwent abdominoperineal resection with
posterior vaginectomy. She was discharged
home on post-operative day seven.
Three days later, the patient returned to
the ED with acute onset of pain and numbness in her left leg secondary to a complete
occlusion of her left common iliac artery, for
which she underwent emergent right internal
iliac artery stent dilation. During this visit,
the patient received an opt-out HIV test. Her
HIV Antigen/Antibody (AG/AB) test came
back positive for HIV-1. Several days later
her viral load resulted at 306,000 copies/mL,
and her CD4 count was 134 cells/mm3. The
patient was previously unaware of her HIV
status, and no prior HIV test results were
available in the electronic medical record despite 40 combined office and ED visits dating
back as far as seven years.

DISCUSSION

In 2006, the Centers for Disease Control and
Prevention (CDC) recommended universal
opt-out HIV screening for all individuals 13
to 64 years of age.4 The CDC also included

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HIV Specialist - March 2021

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