Management of Antiretroviral Therapy and Opportunistic Infections in People Living with HIV Undergoing Hematopoietic Stem Cell Transplant in British Columbia.

Abstract

Background: A growing number of people living with HIV (PLWH) are developing an indication for hematopoietic stem cell transplantation (HSCT). While overlapping immunosuppression and medication interactions make this a complicated situation, the risk is mitigable, and PLWH should have similar access to HSCT as the general population. There are currently no guidelines available for the management of HSCT in PLWH, and through this document we hope to provide initial guidance.

Methods: We performed a non-systematic review of published English-language literature regarding medication and opportunistic infection risk management in both PLWH and HSCT recipients, as well as local, national, and international guidelines. We then generated recommendations for PLWH undergoing HSCT that went through multiple rounds of review with the authors and expert peers.

Results: Patients living with well-controlled HIV are expected to have similar outcomes with HSCT as people without HIV. Focus should be on minimizing interruptions in antiretroviral therapy, avoiding drug-drug interactions (minimized with integrase strand transfer inhibitors), and managing overlapping toxicities. Opportunistic infections common in both advanced HIV and in HSCT include Pneumocystis pneumonia, toxoplasmosis, herpes simplex virus, varicella zoster virus, and cytomegalovirus, with nontuberculous mycobacteria and cryptococcosis being somewhat more common in advanced HIV. Assuming a patient has well-controlled HIV, most of the opportunistic infection risk is due to transplant-related immunosuppression, and we provide specific prophylactic recommendations.

Conclusions: PLWH should have similar access to HSCT as people without HIV, and we offer this document as guidance to support hematology/oncology providers.