To date, results have been heterogeneous and no clear survival benefit demonstrated [53]. This question has not been addressed in prospective studies in HIV-positive

patients. However, a recent multicentre, Target Selective Inhibitor Library retrospective analysis reviewed the outcome of patients with an IPI score 3–5 and made a comparison between those treated with R-CHOP (n = 35) chemotherapy and the more intensive regimen, CODOX-M/IVAC+/−R (n = 15). Overall, the outcome was favourable with 68% achieving a CR and a 2-year progression-free and overall survival of 68% and 70%, respectively. There was no significant difference in remission duration, progression free survival (PFS) or OS between the two treatment groups; however, there were significantly more infections and nonhaematological toxicities in the CODOX-M/IVAC+/−R group [29]. A comparison of 363 patients treated pre and post the introduction of HAART has shown that overall survival

has improved in the HAART era [54]. Although tumour regressions with immune reconstitution are rarely observed with lymphomas, optimizing the immune status of the patient has been shown to reduce opportunistic infections and is associated Dinaciclib manufacturer with superior response rates and survival. Results from Phase II studies and case–control series have reported higher response rates and improved survival with the addition of HAART to CHOP chemotherapy [55–59]. Opinions differ as to whether HAART should be continued during chemotherapy or not. Treatment centres in the US that use the DA-EPOCH regimen have previously suspended HAART because of concern regarding potential adverse pharmacokinetic and pharmacodynamic interactions with chemotherapy and the potential for increased toxicity [60]. In these studies, despite a high response rate, CD4 cell counts fell dramatically during chemotherapy and took months to recover to baseline Vildagliptin levels despite the re-introduction of HAART on completion of chemotherapy. Although this strategy did not appear to adversely affect lymphoma outcomes or increase infectious complications, the treatment

groups have not been large [19,35]. There is concern that the interruption of HAART in patients on therapy prior to lymphoma diagnosis might lead to the development of viral resistance. In Europe, it is usual to continue HAART during chemotherapy, avoiding boosted protease inhibitors wherever possible as they are associated with greater toxicity and drug interactions [61]. A combined approach to care involving HIV physicians and haemato-oncologists ensures awareness that many antiretrovirals have overlapping toxicities with chemotherapeutic agents. The aim in selecting a HAART regimen is to derive the potential benefits of HIV virological suppression and the associated immune reconstitution whilst minimizing any potential toxicity.