AIDS‐associated Kaposi's sarcoma is linked to advanced disease and high mortality in a primary care HIV programme in South Africa

Abstract

BackgroundAIDS-associated Kaposi's sarcoma is an important, life-threatening opportunistic infection among people living with HIV/AIDS in resource-limited settings. In western countries, the introduction of combination antiretroviral therapy (cART) and new chemotherapeutic agents has resulted in decreased incidence and improved prognosis of AIDS-associated Kaposi's sarcoma. In African cohorts, however, mortality remains high. In this study, we describe disease characteristics and risk factors for mortality in a public sector HIV programme in South Africa.MethodsWe analysed data from an observational cohort study of HIV-infected adults with AIDS-associated Kaposi's sarcoma, enrolled between May 2001 and January 2007 in three primary care clinics. Paper records from primary care and tertiary hospital oncology clinics were reviewed to determine the site of Kaposi's sarcoma lesions, immune reconstitution inflammatory syndrome stage, and treatment. Baseline characteristics, cART use and survival outcomes were extracted from an electronic database maintained for routine monitoring and evaluation. Cox regression was used to model associations with mortality.ResultsOf 6292 patients, 215 (3.4%) had AIDS-associated Kaposi's sarcoma. Lesions were most commonly oral (65%) and on the lower extremities (56%). One quarter of patients did not receive cART. The mortality and lost-to-follow-up rates were, respectively, 25 (95% CI 19-32) and eight (95% CI 5-13) per 100 person years for patients who received cART, and 70 (95% CI 42-117) and 119 (80-176) per 100 person years for patients who did not receive cART. Advanced T stage (adjusted HR, AHR = 5.3, p < 0.001), advanced S stage (AHR = 5.1, p = 0.008), and absence of chemotherapy (AHR = 2.4, p = 0.012) were associated with mortality.Patients with AIDS-associated Kaposi's sarcoma presented with advanced disease and high rates of mortality and loss to follow up. Risk factors for mortality included advanced Kaposi's sarcoma disease and lack of chemotherapy use. Contributing factors to the high mortality for patients with AIDS-associated Kaposi's sarcoma likely included late diagnosis of HIV disease, late accessibility to cART, and sub-optimal treatment of advanced Kaposi's sarcoma.ConclusionsThese findings confirm the importance of early access to both cART and chemotherapy for patients with AIDS-associated Kaposi's sarcoma. Early diagnosis and improved treatment protocols in resource-poor settings are essential.

Survival of patients with Kaposi’s sarcoma in the South African antiretroviral treatment era: A retrospective cohort study

“…We found good survival rates of KS patients in routine care, treated with ART and chemotherapy (ABV or oral VP16) and/or radiotherapy for selected patients. The overall one-year survival rate of 78.5% is comparable to survival estimates from other South African studies [8,9,16] , including a clinical trial that used similar chemotherapy regimens [9] . An observational study in the U.S. estimated two-year survival rates comparable to what we found in the late ART period in South Africa (81% and 79%, respectively) [17] .…”

“…The advent of ART dramatically decreased KS incidence, morbidity and mortality in high income countries [2–4] . South Africa addressed its large HIV epidemic by implementing a national ART programme [5–7] , but studies in the early ART era showed that KS morbidity and mortality were still high in South Africa, largely because ART coverage was still too low, and patients with KS were diagnosed late and many who needed chemotherapy did not receive it [8] .…”

Kaposi Sarcoma in HIV Infected Patients

“…Overall cumulative survival was 69% at 1 year and 64% at 2 years, similar data being reported from a primary care HIV programme in South Africa [15]; however, the survival in our study proved to be lower compared to data reported from Chelsea and Westminster Hospital in London, UK [16]. Using Stebbing's prognostic index for AIDS-associated KS [8] regarding the probability of survival, we found similar values compared to Stebbing's study.…”

Kaposi Sarcoma Still A Problem in Our Hiv Infected Persons: A Site Experience

“…(8) Kaposi sarcoma(KS) and Non Hodgkin's lymphoma(NHL) on the other hand are not vaccine preventable therefore early diagnosis is very essential. (9) Factors that have been found to be important in the control and reduction in the incidence of KS and NHL among HIV infected patients are high CD4 level, initiation on HAART and early detection. (10,11) Although these cancers are AIDs defining, most infected patients are not aware of the symptoms to expect therefore they do not look out for them despite being at risk.…”