Open AccessExcellent clinical outcomes and retention in care for adults with HIV‐associated Kaposi sarcoma treated with systemic chemotherapy and integrated antiretroviral therapy in rural Malawi
Author(s) -
Herce Michael E,
Kalanga Noel,
Wroe Emily B,
Keck James W,
Chingoli Felix,
Tengatenga Listern,
Gopal Satish,
Phiri Atupere,
Mailosi Bright,
Bazile Junior,
Beste Jason A,
Elmore Shekinah N,
Crocker Jonathan T,
Rigodon Jonas
Publication year - 2015
Publication title -
journal of the international aids society
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 2.724
H-Index - 62
ISSN - 1758-2652
DOI - 10.7448/ias.18.1.19929
Subject(s) - medicine , sarcoma , stavudine , interquartile range , common terminology criteria for adverse events , nevirapine , lamivudine , neutropenia , viral load , vincristine , chemotherapy , surgery , pediatrics , human immunodeficiency virus (hiv) , antiretroviral therapy , cyclophosphamide , immunology , pathology , hepatitis b virus , virus
HIV‐associated Kaposi sarcoma (HIV‐KS) is the most common cancer in Malawi. In 2008, the non‐governmental organization, Partners In Health, and the Ministry of Health established the Neno Kaposi Sarcoma Clinic (NKSC) to treat HIV‐KS in rural Neno district. We aimed to evaluate 12‐month clinical outcomes and retention in care for HIV‐KS patients in the NKSC, and to describe our implementation model, which featured protocol‐guided chemotherapy, integrated antiretroviral therapy (ART) and psychosocial support delivered by community health workers. Methods We conducted a retrospective cohort study using routine clinical data from 114 adult HIV‐KS patients who received ART and ≥1 chemotherapy cycle in the NKSC between March 2008 and February 2012. Results At enrolment 97% of patients ( n / N =103/106) had advanced HIV‐KS (stage T1). Most patients were male ( n / N =85/114, 75%) with median age 36 years (interquartile range, IQR: 29–42). Patients started ART a median of 77 days prior to chemotherapy (IQR: 36–252), with 97% ( n / N =105/108) receiving nevirapine/lamivudine/stavudine. Following standardized protocols, we treated 20 patients (18%) with first‐line paclitaxel and 94 patients (82%) with bleomycin plus vincristine (BV). Of the 94 BV patients, 24 (26%) failed to respond to BV requiring change to second‐line paclitaxel. A Division of AIDS grade 3/4 adverse event occurred in 29% of patients ( n / N =30/102). Neutropenia was the most common grade 3/4 event ( n / N =17/102, 17%). Twelve months after chemotherapy initiation, 83% of patients (95% CI: 74–89%) were alive, including 88 (77%) retained in care. Overall survival (OS) at 12 months did not differ by initial chemotherapy regimen ( p =0.6). Among patients with T1 disease, low body mass index (BMI) (adjusted hazard ratio, aHR=4.10, 95% CI: 1.06–15.89) and 1 g/dL decrease in baseline haemoglobin (aHR=1.52, 95% CI: 1.03–2.25) were associated with increased death or loss to follow‐up at 12 months. Conclusions The NKSC model resulted in infrequent adverse events, low loss to follow‐up and excellent OS. Our results suggest it is safe, effective and feasible to provide standard‐of‐care chemotherapy regimens from the developed world, integrated with ART, to treat HIV‐KS in rural Malawi. Baseline BMI and haemoglobin may represent important patient characteristics associated with HIV‐KS survival in rural sub‐Saharan Africa.