Cancer burden in women with HIV on Medicaid_ A nationwide analysis

Abstract

Background: Cancer is the leading cause of death in people living with HIV. In the United States, nearly 1 in 4 people living with HIV are women, more than half of whom rely on Medicaid for healthcare coverage. Objective: The objective of this study is to evaluate the cancer burden of women living with HIV on Medicaid. Design: We conducted a cross-sectional study of women 18–64 years of age enrolled in Medicaid during 2012, using data from Medicaid Analytic eXtract files. Methods: Using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes, we identified women living with HIV (n = 72,508) and women without HIV (n = 17,353,963), flagging the presence of 15 types of cancer and differentiating between AIDS-defining cancers and non-AIDS-defining cancers. We obtained adjusted prevalence ratios and 95% confidence intervals for each cancer and for all cancers combined, using multivariable log-binomial models, and additionally stratifying by age and race/ethnicity. Results: The highest adjusted prevalence ratios were observed for Kaposi’s sarcoma (81.79 (95% confidence interval: 57.11–117.22)) and non-Hodgkin’s lymphoma (27.69 (21.67–35.39)). The adjusted prevalence ratios for anal and cervical cancer, both of which were human papillomavirus-associated cancers, were 19.31 (17.33–21.51) and 4.20 (3.90–4.52), respectively. Among women living with HIV, the adjusted prevalence ratio for all cancer types combined was about two-fold higher (1.99 (1.86–2.14)) in women 45–64 years of age than in women 18–44 years of age. For non-AIDS-defining cancers but not for AIDS-defining cancers, the adjusted prevalence ratios were higher in older than in younger women. There was no significant difference in the adjusted prevalence ratios for all cancer types combined in the race/ethnicity-stratified analyses of the women living with HIV cohort. However, in cancer type–specific sub-analyses, differences in adjusted prevalence ratios between Hispanic versus non-Hispanic women were observed. For example, the adjusted prevalence ratio for Hispanic women for non-Hodgkin’s lymphoma was 2.00 (1.30–3.07) and 0.73 (0.58–0.92), respectively, for breast cancer. Conclusion: Compared to their counterparts without HIV, women living with HIV on Medicaid have excess prevalence of cervical and anal cancers, both of which are human papillomavirus related, as well as Kaposi’s sarcoma and lymphoma. Older age is also associated with increased burden of non-AIDS-defining cancers in women living with HIV. Our findings emphasize the need for not only cancer screening among women living with HIV but also for efforts to increase human papillomavirus vaccination among all eligible individuals.