Background: HIV+ persons have an elevated risk of lung cancer, due in part to a high prevalence of smoking. Prior studies are limited by the inability to directly control for smoking.

Methods: Since 1988, the ALIVE Study has prospectively followed a cohort of injection drug users (IDUs) in Baltimore, MD with semi-annual collection of clinical, laboratory and behavioral data. Clinical diagnoses are confirmed through medical record abstraction. Lung cancer deaths were identified through linkage with the National Death Index. Cox proportional hazards regression was used to examine the effect of HIV infection on lung cancer death, while controlling for other covariates including smoking (average packs / day) and drug use variables.

Results: Among 2,960 ALIVE participants followed for ~22,000 person-years, we identified 27 individuals that died from lung cancer; 14 were HIV+ and 13 HIV-. Although not statistically significant, lung cancer death rates were increased in the post-HAART (after 7/1/96) compared to pre-HAART era (RR 1.98, 95% CI: 0.83-5.22). HIV+ cases were slightly younger than HIV-‘s (51 vs. 55 yrs, p=0.06) but had similar gender, racial, smoking and drug use patterns. Smoking and age >50 were strongly associated with lung cancer mortality. After adjusting for age, gender and smoking, HIV+’s had a 3.04 increased hazard for lung cancer death compared to HIV-‘s (1.39-6.65). Further, recurrent pneumonia (2 or > hospitalizations) was associated with lung cancer death (RH 1.99; 1.10-9.20) and explained some of the HIV effect (RH reduced to 2.34; 1.01-5.43). Neither injection nor inhaled drug use were associated with lung cancer mortality. Among HIV+ lung cancer deaths, the median CD4 nadir was 208 cells/μl and HIV RNA maximum level was 133,000 copies/ml; only 5 of 14 had ever received HAART. Smoking and age >50 remained the primary risk factors in analysis of HIV+’s only; CD4 count, viral load and HAART use were not associated with lung cancer mortality.

Conclusions: With prolonged survival of HIV+ persons in the post-HAART era, lung cancer deaths are increasing. After controlling for the high prevalence of smoking, HIV infection remained a significant risk factor for dying from lung cancer. Increased lung cancer risk following recurrent pneumonia may explain some but not all of this association. Although the sample size is small, lung cancer mortality among HIV+’s was not associated with history of advanced immune suppression nor with HAART use.