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HIV Medicine 2007 Preliminary Edition 194 pages Download PDF, 1.0 MB Collaborators About
HAART
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The incidence of HD is elevated in HIV-infected patients by a factor of 5-10 compared to the HIV-negative population. For particular subtypes, such as lymphocyte-depleted and mixed-cellularity HD, the relative risk is presumably much higher (Frisch 2001). Despite this and the growing realization that these subtypes at least are clearly associated with immunodeficiency, HIV-HD is not included as an AIDS-defining illness. An advanced stage of disease at diagnosis is typical, as is frequent extranodal involvement and a trend towards prognostically poorer subtypes (Tirelli 1995, Rapezzi 2001, Thompson 2004). Mediastinal disease is significantly less frequent than in HIV-negative patients. A further difference to HD in seronegative patients is the predominance of cases with Reed-Sternberg cells, as well as the clear association with EBV infection, which is 80-100 %, depending on the study. EBV infection is therefore seen as an important etiologic factor for development of HIV-HD. In comparison to HIV-negative HD, which is a highly treatable tumor, the prognosis of HIV-HD is poor. In nearly all cohorts with more than 20 patients from the pre-HAART era, the median survival was only between 15-20 months, respectively (Andrieu 1993, Errante 1999, Levine 2000, Tirelli 1995). The response to chemotherapy was also moderate compared to the normal population. Complete remission rates were between 40-80 %, and hematological and infectious complications were frequent. Even if there are initial indications that this is changing in the era of HAART, as with NHL, there is little data so far. In our own multicenter cohort of 56 patients, the median survival was 40 months. In patients with adequate HAART, the two-year survival rate was 84 %, which is encouraging (Hoffmann 2004). In the meantime, other groups have also reported better prognoses with HAART (Ribera 2002, Gérard 2003). Signs and symptoms B symptoms occur in the majority of cases. Extranodal and advanced stages are almost always the rule. Lymphomas are firm, immobile or hardly mobile and painless, and the distinction from HIV lymphadenopathy or tuberculous lymphadenitis is not always possible. Diagnosis Staging is necessary as for non-Hodgkin lymphomas (see relevant section). Diagnostic lymph node extirpation is even more important here than with NHL, as puncture only rarely allows diagnosis of Hodgkin's disease. Single accurate diagnostics are better than half-heartedly bothering the patient with repeated punctures and losing time unnecessarily! Surgical extirpation is possible as an outpatient in many centers. As with NHL, specimens should be sent to reference laboratories if possible. Since bleomycin will be administered, a lung function test should always precede the first chemotherapy. Treatment Many clinicians still favor the classical ABVD regimen (four double cycles) for HIV patients. ABVD is the abbreviation for the combination chemotherapy with the cytostatics adriamycin, bleomycin, vinblastine and DTIC (dacarbazine). Ambulatory treatment is possible. It should be contemplated, however, whether this therapy is still sufficient in the HAART era, particularly for advanced stages of the disease. 
In HIV-negative patients with advanced stages (as is almost always the case for HIV-HD) the BEACOPP regimen of the German Hodgkin Study Group has been used in the last years, mainly with escalated dosing. This has proven to be significantly more effective, both with regard to response rates and long-term survival. However, the BEACOPP regimen is more toxic. Whether these positive results can be seen in HIV-HD is still not clear. However, based on initial reports and our own experience, BEACOPP seems to be possible (Hartmann 2003). There is also growing experience to date with the Stanford V protocol, for which there have recently been promising reports (Spina 2002). References
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