Assessing the outcomes of HIV-infected persons receiving treatment for Kaposi sarcoma in Conakry-Guinea

Abstract

BackgroundMédecins Sans Frontières is supporting comprehensive HIV care and treatment for Kaposi Sarcoma (KS) in Guinea, where antiretroviral coverage is low and access to KS treatment is very limited. We aimed to evaluate treatment response and survival outcomes of epidemic KS in this setting.MethodsRetrospective survival analysis of routinely collected clinical data of HIV-infected patients with clinically diagnosed KS, receiving ART and chemotherapy consisting of a combination of bleomycin and vincristine at the Donka National Hospital in Conakry between 2012 and 2015.ResultsA total of 225 patients were enrolled for KS treatment within the three-year period. Late presentation with stage T1 disease was common (82.7%). At the end of a median of 8 cycles of chemotherapy (IQR: 2–12), complete remission was observed in 65 (28.9%), partial remission in 53 (23.6%), stable disease in 15 (6.7%) and unknown response for all 92 (40.9%) patients who dropped out of care. The chances of achieving complete remission doubled after each additional cycle of chemotherapy (aOR = 2.09 95% CI: 1.44–3.01) but were reduced by about two-thirds for each additional month delay between treatment and onset of KS (aOR = 0.31, 95% CI: 0.11–0.86). Treatment response was seriously compromised in patients with woody skin oedema (aOR = 0.05, 95% CI: 0.01–0.38) and those with prior chemotherapy (aOR = 0.21, 95% CI: 0.05–0.80). The median survival time was 7.6 months (95% CI: 5.9–9.8). Attrition from care was reduced by 22% for every additional cycle of chemotherapy administered (aH0R = 0.78, 95% CI: 0.71–0.84) and was lower in those with complete remission compared with those with partial or no response (aHR = 0.05, 95% CI: 0.007–0.43).ConclusionThere has been an increased access to KS treatment. The overall response rate is 52.4%, which is considered a satisfactory result. Poor outcomes were common and were largely due to late presentation and defaulting on treatment. Efforts towards early HIV/KS diagnosis and adherence to a full round of chemotherapy are needed for optimising outcomes. Newer drugs may be required for patients previously exposed to chemotherapy.Electronic supplementary materialThe online version of this article (10.1186/s12885-017-3771-x) contains supplementary material, which is available to authorized users.

Real-world use of chemotherapy for Kaposi’s sarcoma in a large community-based HIV primary care system in Kenya

“…A particular strength of our study comes from linking severity of disease at time of diagnosis with subsequent treatment course in a real-world setting. Similar to other resource poor settings, most patients in this Kenyan setting were diagnosed with KS when their disease was already at advanced stage, and not all patients had histologically confirmed disease [8,25,31,32]. We found that patients who were on ART for > 60 days prior to KS diagnosis were diagnosed at less advanced KS disease stage, which could either be due to the effects of ART itself (though we do not know who was virally suppressed), or due to the more frequent contact these patients had with the health system.…”

“…Prior studies on KS treatment with chemotherapy in sub-Saharan Africa have focused on outcomes of particular chemotherapy regimens, [17,18,[25][26][27] neither evaluated real-world delays in chemotherapy initiation, nor, perhaps most importantly, chemotherapy non-initiation in patients with chemotherapy indications. We know that there is often a significant delay between symptom recognition and successful initiation of cancer care in Africa [28].…”

Beyond T Staging in the Treat All Era: Capturing the Severity and Heterogeneity of Kaposi’s Sarcoma in East Africa

“…These findings are similar to prior studies in sub-Saharan Africa reporting that 69 to 89% of KS patients present with T1 disease. 4,5,7,21,22 This finding contrasts with high income countries where there is much less T1 disease, with recent estimates of 34-35%. 14,23 Compared to prior studies, our documentation of advanced stage of disease is likely more representative and proximal in a multi-site sub-Saharan African setting.…”

“…However, the question remains which signs or symptoms of KS are predictive of KS mortality. In addition to TIS staging predictors, previous studies from both high and low income settings have found that pulmonary involvement, 11 woody edema, 22 low BMI, 26 low hemoglobin, 26 low albumin, 25 older age, 23 decreased performance status, 23,25 and positive HHV-8 DNA to be predictive of mortality. 6,27 The linkage of staging criteria with outcomes has recently been performed in the pediatric KS literature in Malawi, but has not yet been performed for the adult KS population in sub-Saharan Africa during the treat-all era.…”

Using Media to Promote Public Awareness of Early Detection of Kaposi’s Sarcoma in Africa

“…In spite of the incidence of KS in sub-Saharan Africa and its hallmark presentation on the skin and visible mucous membranes (i.e., in areas where it theoretically can be detected in an early stage), more than 80% of all KS in sub-Saharan Africa is classified as late-stage at the time of diagnosis (2)(3)(4). Like many cancers, KS diagnosed in advanced stages has worse survival than early diagnosis (4,5). Probably more than most cancers, however, detecting KS early in sub-Saharan Africa could likely largely control the condition.…”