Background
In 2015, the WHO recommended initiation of ART in all persons living with HIV, regardless of CD4 count or clinical stage, the dawning of the “Treat All” era. The intention of “Treat All” is to detect and treat HIV infection in its earliest stages. At the most macroscopic level, “Treat All” has been successful in most resource-limited settings, diminishing all-cause death related to HIV. What is less understood is whether all individual severe HIV-related complications have benefitted equally. We investigated how one oncologic complication — Kaposi sarcoma (KS) — has fared by examining when it develops in relationship to diagnosis of HIV infection.
Methods
We identified adults (aged ≥ 18 years) with a new diagnosis of KS made between October 2022 and June 2024 in both inpatient and outpatient settings at several sites in East Africa that offer free-of-charge skin biopsy services: Uganda (Infectious Diseases Institute, Masaka and Mbarara Regional Referral Hospitals, and St. Mary’s Hospital Lacor); Kenya (Academic Model Providing Access to Healthcare network); and Tanzania (Muhimbili Univ. of Health and Allied Sciences). KS was confirmed by histopathology except in those with lesions that were deemed unsafe to biopsy. We used interviewer-administered questionnaires to collect data on HIV diagnosis and KS history. Using the date that patients reported to have first noticed KS lesions and the date they reported HIV diagnosis was made, we describe the timing of KS lesion development in relation to HIV diagnosis.
Results
Among 501 adults with a new diagnosis of HIV-related KS, 67% were men and the median (IQR) age was 36 (30-42) years. Median monthly household income was <$100 US. Among 482 patients with evaluable dates, 50% first noticed KS lesions ≥ one month prior to HIV diagnosis, 13% noticed lesions within ± 1 month of HIV diagnosis (the exact sequence could not be determined), and 37% noticed lesions ≥ 1 month after HIV diagnosis
Conclusions
Amongst adults with newly diagnosed KS in East Africa in the ‘Treat all’ era, half developed KS prior to the health care system’s diagnosis of HIV infection. This indicates a need to improve HIV screening strategies in order to have HIV diagnosis made earlier, thus preventing progression to KS. The large proportion of patients developing KS after HIV diagnosis represents another research priority — why is this occurring and how can it be prevented?
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