By Landon Gray
A 66-year-old patient living with HIV and acute myeloid leukemia (AML) achieved complete remission from both his HIV and AML after a hematopoietic stem cell transplant (HSCT) without the need for additional immunotherapy and radiation.
The patient, who has been living with HIV for more than three decades, is the oldest patient living with HIV and AML to date to successfully undergo the procedure, explained Jana K. Dickter, MD, an associate clinical professor in the Division of Infectious Diseases at City of Hope National Medical Center, in Duarte, Calif., as she highlighted the case data during a press conference at the International AIDS 2022 Conference, in Montreal.
“He was the oldest person to successfully undergo a stem cell transplant with HIV and leukemia, and then achieve remission from both conditions. He had been living with HIV the longest of any of the patients to date, for more than 31 years prior to transplant,” Dr. Dickter said.
In 2019, at the age of 63, the patient underwent HSCT for AML from an unrelated donor. The unrelated donor’s cells had a rare genetic mutation that prohibits the acquisition of HIV—identified as homozygous CCR5-delta 32. The CCR5 mutation blocks the path of HIV and hinders its ability to infect Cd4+ cells and barrage the immune system. The patient has been in remission for 17 months.
The patient received a chemotherapy-based, reduced-intensity transplant regimen prior to his transplant that was developed by City of Hope and other transplant programs for the treatment of older patients with blood cancers. Reduced-intensity chemotherapy makes the transplant more tolerable for older patients and reduces the potential for transplant-related complications from the procedure.
Under the care of City of Hope hematologist Ahmed Aribi, MD, an assistant professor in the Division of Leukemia, the patient received three different therapies to get him into remission before undergoing HSCT. Most patients achieve remission after one therapy. The remission is necessary because a transplant is an intensive procedure that can cause serious complications. The patient did not experience serious medical issues after the transplant.
“This patient had a high risk for relapsing from AML, making his remission even more remarkable and highlighting how City of Hope provides excellent care treating complicated cases of AML and other blood cancers,” Dr. Aribi said.
Since the transplant, the City of Hope patient has not shown any evidence of replicating HIV virus, and stopped taking antiretroviral therapy (ART) in March 2021. He might have been able to stop the therapies sooner but wanted to wait until he was vaccinated against COVID-19.
Previously, three patients also reached remission. However, these patients received additional therapy, such as total body irradiation, as well as further immunosuppressive therapy. The City of Hope patient did not receive any of those therapies.
The patient received reduced-intensity conditioning with fludarabine and melphalan, and his graft-versus-host disease prophylaxis was tacrolimus and sirolimus, which also differed from his predecessors.
“The City of Hope patient was able to receive a less intensive chemotherapy regimen that City of Hope and other transplant programs have developed for older and less fit patients prior to transplant. This regimen makes an allogeneic transplant or a transplant from donor cells possible for this patient population to achieve remission from their respective cancer,” Dr. Dickter said.
She explained that this regimen has shown to be better tolerated by older patients with blood cancers, and in turn, reducing the potential for transplant related complications.
“We now have evidence that some HIV patients with blood cancers may not need fully intensive immunosuppressive therapies prior to transplant in order to put them into remission from HIV and leukemia,” said Dr. Dickter, adding that the results from this patient are profound.
With the life expectancy of people living with HIV (PLWH) increasing due to the advances in ART, “this case opens up possibilities for other older [PLWH] and a blood cancer to receive a transplant and achieve remission from both diseases if a donor with this rare genetic mutation can be identified.”
Due to the complex nature of the stem cell transplant procedure, there are significant, potential side effects, making this option less suitable for most PLWH, but more viable for those who also develop blood cancers.
