A Population-Level Evaluation of the Effect of Antiretroviral Therapy on Cancer Incidence in Kyadondo County, Uganda, 1999–2008

Abstract

Background The introduction of antiretroviral therapy (ART) in the US and Europe has led to changes in the incidence of cancers among HIV- infected persons, including dramatic decreases in Kaposi sarcoma (KS) and non-Hodgkin lymphoma (NHL), and increases in Hodgkin lymphoma (HD), liver and anogenital malignancies. We sought to evaluate whether increasing availability of ART is associated with changing cancer incidence in Uganda. Methods Incident cases of 10 malignancies were identified from Kampala Cancer Registry from 1999 to 2008. ART coverage rates for Uganda were abstracted from UNAIDS reports. Negative binomial and poisson regression modeled the association between ART coverage and age-adjusted cancer incidence. Results ART coverage in Uganda increased from 0 to 43% from 1999 to 2008. With each 10% increase in ART coverage, incidence of Kaposi sarcoma decreased by 5%(incidence rate ratio [IRR]=0·95, 95% CI: 0·91–0·99, P=0·02) and stomach cancer decreased by 13% (IRR=0·87 [0·80–0·95], P=0·002). Conversely, incidence of non-Hodgkin lymphoma increased by 6% (IRR=1·06 [1–1·12], P=0·05), liver cancer by 12% (IRR=1·12 [1·04–1·21], P=0·002), prostate cancer by 5% (IRR=1·05 [1–1·10], P=0·05), and breast cancer by 5% (IRR=1·05 [1–1·11], P=0·05). ART coverage was not associated with incidence of invasive cervical cancer, lung, colon, and Hodgkin disease. These findings were similar when restricted to histologically confirmed cases. Conclusion Our findings suggest that AIDS-defining malignancies and other malignancies are likely to remain significant public health burdens in sub-Saharan Africa even as ART availability increases.

A decade of HIV care in rural Tanzania: Trends in clinical outcomes and impact of clinic optimisation in an open, prospective cohort

“…Our observed prevalence in 2014 of 5% is consistent with other studies (3–7.1% [30]). While globally the incidence of Kaposi sarcoma is decreasing with increasing ART coverage [31,32], we observed increasing prevalence over time, reaching 3.6% among patients enrolled in 2014 with low CD4 count, most likely due to improved detection, although the limitations of physician-diagnosis are known [33]. Among the same KIULARCO patients, PCP prevalence was lower than in a recent meta-analysis of studies conducted between 1995 and 2015 (5.8% versus 15.4%) but the authors found substantial heterogeneity by time, clinical setting and diagnostic method [34].…”

Evolving epidemiology of HIV-associated malignancies

“…Most African countries lack population-based cancer registry data that allow an assessment of cancer burden. Nonetheless, analyses of incidence data from cancer registries in Uganda and Botswana provide evidence for recent declines in KS that are temporally associated with uptake of HAART [47, 48]. …”

HIV-associated malignancies in sub-Saharan Africa

“…Similarly, in both China and Brazil, relative ADC declines and NADC increases are occurring as in high-income countries [16*, 17*]. Conversely, in most of SSA, ADC still dominate with incidence declines most consistently observed for KS, although KS incidence remains high throughout the region and is often among the most frequent cancers overall [15**, 18*, 19*, 20, 21**, 22]. HIVAM are therefore unlikely to recede as a public health problem in LMIC in the near term despite ART scale-up.…”