Hepatocellular carcinoma in people living with HIV

People living with HIV (PLWH) carry a higher risk of developing chronic liver disease and hepatocellular carcinoma (HCC). This relates to shared transmission pathways of HIV and viral hepatitis and a plethora of direct and indirect effects of HIV on the progression of chronic liver disease and HCC. In the absence of active cancer treatment, the prognosis of PLWH affected by HCC is worse than matched controls without HIV. However, evolving evidence suggests that active/curative treatments for HCC, including liver transplantation, locoregional treatment, and systemic treatment, confer similar benefit in PLWH as in people without HIV, underscoring that well-controlled HIV infection should not be a barrier to the delivery of cancer care. Nevertheless, PLWH have historically been excluded from interventional clinical trials, and most of the evidence supporting clinical decision making in this population comes from small retrospective studies, further complicating the management of PLWH affected by HCC. Furthermore, whether the biology of the tumour and its microenvironment is influenced by HIV and affects response to treatment is incompletely understood. In this review, we summarise the current understanding of pathophysiology, screening and management of HCC in PLWH and discuss the persisting challenges and disparities in care which may contribute to adverse clinical outcomes in PLWH.