title: AIDS-associated Kaposi's sarcoma is linked to advanced disease and high mortality in a primary care HIV programme in South Africa.
abstract: BACKGROUND
  AIDS-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.
  
  
  METHODS
  We 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.
  
  
  RESULTS
  Of 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.
  
  
  CONCLUSIONS
  These 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.
authors.affiliation: Médecins Sans Frontières, Braamfontein, Johannesburg, South Africa. kathryn.chu@joburg.msf.org
authors.forename: Kathryn M
authors.initials: KM
authors.lastname: Chu
authors.forename: Gcina
authors.initials: G
authors.lastname: Mahlangeni
authors.forename: Sarah
authors.initials: S
authors.lastname: Swannet
authors.forename: Nathan P
authors.initials: NP
authors.lastname: Ford
authors.forename: Andrew
authors.initials: A
authors.lastname: Boulle
authors.forename: Gilles
authors.initials: G
authors.lastname: Van Cutsem
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy / Q000453:epidemiology / Q000209:etiology / Q000401:mortality*; D000163:Acquired Immunodeficiency Syndrome / Q000150:complications* / Q000188:drug therapy / Q000401:mortality; D000328:Adult; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D012307:Risk Factors; D012514:Sarcoma, Kaposi / Q000188:drug therapy / Q000453:epidemiology / Q000209:etiology / Q000401:mortality*; D013019:South Africa / Q000453:epidemiology