Increasing Numbers of New Kaposi Sarcoma Diagnoses in HIV-Infected Children and Adolescents Despite the Wide Availability of Antiretroviral Therapy in Malawi

To the Editor—It is with great interest that we read the recently published manuscript on Kaposi sarcoma (KS) risk in human immunodeficiency virus (HIV)–infected children worldwide [1]. The particularly high incidence rate of pediatric KS reported in eastern Africa is striking. The experience in our pediatric HIV-related malignancy program in Lilongwe, Malawi, is consistent with the epidemiologic data from the Pediatric AIDS-Defining Cancer Project Working Group. In eastern and central Africa— where human herpesvirus 8 (HHV-8) is endemic and prevalence rates are highest in the world—KS is among the 3 most common childhood cancers overall [2–5]. With the increased availability of combination antiretroviral therapy (cART) in sub-Saharan Africa over the past decade, it is important to determine trends in KS. Data from South Africa and Zambia demonstrate that in adults, the risk for KS and incidence rates remain high despite increased cART coverage [6, 7]. We retrospectively investigated trends in pediatric KS from 2006 to 2015 in our pediatric (<18 years of age) HIV-related malignancy program at the Baylor College of Medicine International Pediatric AIDS Initiative Center of Excellence in Lilongwe, Malawi. The scale-up in delivering cART to children in the Malawian national antiretroviral program began in 2005. Since then, >50 000 children have been initiated on cART, including 3964 at our center. Despite the substantial increase in cART coverage in Malawi, the annual number of new KS diagnoses in HIVinfected children and adolescents has steadily increased over the past decade (Figure 1). The average annual number of new pediatric KS diagnoses from 2006 to 2010 (n = 89) was 17.8 cases per year, compared to 25.2 cases per year from 2011 to 2015 (n = 126). We also compared numbers of new KS diagnoses in HIV-infected children and adolescents from our 2 published cohorts [8, 9]. In the recent cohort, 70 patients were diagnosed with KS over 34 months from 2010 to 2013. That represented 5.2% (70/1359) of all children initiated on cART at our center [9]. The historical control reported 72 patients with KS from 2003 to 2009 (total duration 80 months), representing 3.2% (72/2241) of cART initiations [8]. The older cohort averaged 0.9 new KS diagnoses per month vs 2.1 new KS diagnoses per month more recently. It is evident that the number of new pediatric KS diagnoses in Malawi is not yet decreasing despite wider availability of cART. Recent data from Blantyre, Malawi, reveal similar numbers [10]. Several factors that may contribute to the current increased numbers of pediatric KS diagnoses include improved referral networks via outreach to regional healthcare professionals, facilities, and patients through our Tingathe Community Outreach Program, improved infrastructure to establish definitive diagnoses via biopsies (especially in lymph node KS), and persistent gaps in access to cART. Despite great efforts to reduce the severe complications of pediatric HIV infection with cART, KS still remains an important complication in HHV-8– endemic regions of Africa. Our experience has demonstrated that long-term complete remission may be achieved in childhood KS with the combination of relatively moderate chemotherapy and