title: Hodgkin lymphoma, HIV, and Epstein-Barr virus in Malawi: Longitudinal results from the Kamuzu Central Hospital Lymphoma study.
abstract: Contemporary descriptions of classical Hodgkin lymphoma (cHL) are lacking from sub-Saharan Africa where human immunodeficiency virus (HIV) and Epstein-Barr virus (EBV) are prevalent.
  
  
  
  We describe a prospective cHL cohort in Malawi enrolled from 2013 to 2015. Patients received standardized treatment and evaluation, including HIV status and EBV testing of tumors and plasma.
  
  
  
  Among 31 patients with confirmed cHL, the median age was 19 years (range, 2-51 years) and 22 (71%) were male. Sixteen patients (52%) had stage III/IV, 25 (81%) B symptoms, and 16 (52%) performance status impairment. Twenty-three patients (74%) had symptoms >6 months, and 11 of 29 (38%) had received empiric antituberculosis treatment. Anemia was common with median hemoglobin 8.2 g/dL (range, 3.1-17.1 g/dL), which improved during treatment. No children and 5 of 15 adults (33%) were HIV+. All HIV+ patients were on antiretroviral therapy for a median 15 months (range, 2-137 months), with median CD4 count 138 cells/μL (range, 23-329 cells/μL) and four (80%) having undetectable HIV. EBV was present in 18 of 24 (75%) tumor specimens, including 14 of 20 (70%) HIV- and 4 of 4 (100%) HIV+. Baseline plasma EBV DNA was detected in 25 of 28 (89%) patients, with median viral load 4.7 (range, 2.0-6.7) log10copies/mL, and subsequently declined in most patients. At 12 months, overall survival was 75% (95% confidence interval [CI], 55%-88%) and progression-free survival 65% (95% CI, 42%-81%). Baseline plasma EBV DNA and persistent viremia during treatment were associated with poorer outcomes.
  
  
  
  cHL in Malawi is characterized by delayed diagnosis and advanced disease. Most cases were EBV associated and one-third of adults were HIV+. Despite resource limitations, 12-month outcomes were good.
authors: UNC Project-Malawi, Lilongwe, Malawi.|Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina.
authors: Katherine D
authors: KD
authors: Westmoreland
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: Christopher C
authors: CC
authors: Stanley
authors: Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina.
authors: Nathan D
authors: ND
authors: Montgomery
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: Bongani
authors: B
authors: Kaimila
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: Edwards
authors: E
authors: Kasonkanji
authors: Section of Hematology/Oncology, Texas Children's Hospital, Houston, Texas.
authors: Nader Kim
authors: NK
authors: El-Mallawany
authors: Section of Hematology/Oncology, Texas Children's Hospital, Houston, Texas.|Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
authors: Peter
authors: P
authors: Wasswa
authors: Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
authors: Idah
authors: I
authors: Mtete
authors: Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
authors: Mercy
authors: M
authors: Butia
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: Salama
authors: S
authors: Itimu
authors: Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
authors: Mary
authors: M
authors: Chasela
authors: Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
authors: Mary
authors: M
authors: Mtunda
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: Maria
authors: M
authors: Chikasema
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: Victor
authors: V
authors: Makwakwa
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: Coxcilly
authors: C
authors: Kampani
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: Bal M
authors: BM
authors: Dhungel
authors: Department of Microbiology & Immunology, University of North Carolina, Chapel Hill, North Carolina.
authors: Marcia K
authors: MK
authors: Sanders
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: Robert
authors: R
authors: Krysiak
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: Tamiwe
authors: T
authors: Tomoka
authors: UNC Project-Malawi, Lilongwe, Malawi.
authors: N George
authors: NG
authors: Liomba
authors: UNC Project-Malawi, Lilongwe, Malawi.|Department of Microbiology & Immunology, University of North Carolina, Chapel Hill, North Carolina.
authors: Dirk P
authors: DP
authors: Dittmer
authors: Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina.
authors: Yuri
authors: Y
authors: Fedoriw
authors: UNC Project-Malawi, Lilongwe, Malawi.|Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi.|Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
authors: Satish
authors: S
authors: Gopal
mesh_terms: D000293:Adolescent; D000328:Adult; D018791:CD4 Lymphocyte Count; D002648:Child; D002675:Child, Preschool; D004279:DNA, Viral / Q000097:blood; D018572:Disease-Free Survival; D020031:Epstein-Barr Virus Infections / Q000150:complications / Q000453:epidemiology*; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000453:epidemiology*; D015497:HIV-1 / Q000235:genetics / Q000302:isolation & purification*; D004854:Herpesvirus 4, Human / Q000235:genetics / Q000302:isolation & purification*; D006689:Hodgkin Disease / Q000150:complications / Q000453:epidemiology*; D006801:Humans; D008137:Longitudinal Studies; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D019562:Viral Load; D014766:Viremia / Q000821:virology; D055815:Young Adult
chemical_list: D004279:DNA, Viral
keywords: Epstein-Barr virus; Hodgkin lymphoma; Malawi; pediatric cancer; sub-Saharan Africa