Boulle, A

Chu, K

Ford, Nathan

Mahlangeni, G

Stead, David

Swannet, S

Van Cutsem, G

English

MSF Field Research

Determinants of Mortality and Disease Progression of Kaposi Sarcoma in a Primary 
Care ART Programme in Khayelitsha, South Africa
8
6
1
Kathryn Chu 1, Gcina Mahlangeni 1, Sarah Swannet 1, Nathan Ford1,2, David Stead 1, Andrew Boulle 2 & Gilles Van Cutsem 1,2
Ph: +27-21-364 5490
Fx: +27-21-361 7051
gillesvancutsem@gmail.com
www.msf.org.za
Médecins Sans Frontières
Cape Town, South Africa
1.
Fax: +27-21-406-6764
University of Cape Town
Ph:   +27-21-406-6711
andrew.boulle@uct.ac.za
www.ideu.uct.ac.za
2.
School of Public Health and Family Medicine
Table 5: Evolution of Kaposi Sarcoma 
Discussion and conclusions
 The prevalence of diagnosed KS among patients starting ART in Khayelitsha was low. However, the 
high proportion of high risk disease (T1S1) could be explained by a combination of late presentation 
and under-diagnosis  of low risk disease.
 Despite the advent of ART and the availability of chemo- and radiotherapy mortality remained high.
 Loss to follow-up before and after initiation of treatment was higher than in non-KS HIV-infected 
patients.
 The major determinant for mortality and disease progression was advanced disease (stage T1 or S1), 
with systemic symptoms (stage S1) being associated with higher mortality and stage T1 with 
increased disease progression.
 Addition of chemotherapy to ART was independently associated with a 70% decrease in mortality.
 Improved studies on the effectiveness of accessible chemotherapy regimens and related side-effects 
in resource-limited settings are needed. 
 Efforts to improve early diagnosis and retention in care for patients with KS are also needed.
Background & Setting
Baseline Characteristics of Patients with Kaposi sarcoma
Types of Treatment of Kaposi Sarcoma
Background:  Kaposi Sarcoma (KS) is the most common HIV-related malignancy. In the developed world, antiretroviral 
therapy (ART) appears to influence the clinical course of AIDS related KS; partial and complete regressions have been 
widely reported. Little is known about the evolution of KS on ART in poor resource settings.   
Methods: We conducted a retrospective study of patients with KS enrolled on ART in a primary care setting (Khayelitsha 
Township, South Africa) between May 2001 and January 2007. Site of lesion, grading, treatment, and outcomes on ART 
are described. Logistic regression was used to model determinants of mortality and disease progression on ART.
Results: Of 15,000 adults enrolled into HIV care in Khayelitsha during the study period, 214 (1.4%) had KS.  A folder 
review was done for 188 (88%) of these patients. Median age was 34 years, median baseline CD4 count 73 cells/µl (IQR, 
26-171) and the majority (60%) were female. The most common sites of lesions were oral (65%) and the lower 
extremities (56%); 124 (69%) had T1 and 148 (82%) S1 disease. Forty-five (24%) patients were not treated and 70 (37%) 
were treated with ART alone.  Of the 86 patients referred for further treatment, 55 (64%) received chemotherapy, 45 
(51%) received radiotherapy, and 2 (2%) underwent surgery.  Seven (5%) of 137 developed symptoms of KS immune 
reconstitution syndrome on ART.   KS outcome data was available for 94 patients (50%). Of these, 18 (19%) had 
complete remission of lesions, 43 (46%) had partial improvement, 8 (8%) had no change in lesions, and 25 (26%) had 
progressive disease. Sixty-six (35%) patients had died, 47 (25%) were lost to follow-up, 9 (5%) were transferred out, and 
62 (33%) were alive and in care at the end of the study.  In multivariate analysis, stage T1 and S1 disease were associated 
with mortality (OR respectively 7.4, p<0.001 and 18.6, p=0.007) and  disease progression (OR 20.7, p=0.011 and 10.1, 
p=0.037). Chemotherapy was associated with a decreased risk of death (OR 0.3, p=0.027) and disease progression (OR 
0.4, p=0.129).
Conclusions: The prevalence of KS among patients starting ART in Khayelitsha was low.  However, despite the advent 
of ART and other treatments for KS, mortality remained very high (60% if losses to follow-up are counted as dead).  Loss 
to follow-up before and after initiating treatment was high. The major risk factors for mortality and disease progression 
were advanced (T1 or S1) disease. Chemotherapy was associated with a 70% (95% CI 10-90%) reduction in mortality. 
Improved studies on the effectiveness of accessible chemotherapy regimens and related side-effects in resource-limited 
settings are needed. Efforts to improve retention in care for patients with KS are also needed.
ABSTRACT
Location of Lesions
Kaposi Sarcoma Treatment Outcomes
n=188 
Disseminated Cutaneous Lesions 72 (38.3)
Site of Lesions
Oral 122 (64.9)
Head 78 (41.5)
Trunk 68 (36.2)
Upper Extremity 63 (33.5)
Lower Extremity 105 (56.2)
Lymphadenopahthy 42 (22.3)
Lymphoedema 42 (22.3)
Gastrointestinal  4 (2.1)
Lung** 37 (19.7)
*Total more than 188 as each patient could have more than one lesion
Determinants of Mortality and Disease Progression
n=94
Complete remission of lesions 18 (19.2%)
Partial Improvement 43 (45.7%)
No change in lesions 8 (8.5%)
Progessive disease 25 (26.6%)
n=188
No treatment 45 (23.9%)
Antiretroviral Therapy Only 70 (37.2%)
Chemotherapy 55 (29.3%)
Bleomycin 28 (50.9%)
Adriamycin 29 (52.7%)
Vincristine 28 (50.9%)
Vinblastine 26 (47.3%)
Radiotherapy 45 (23.9%)
Surgery 2 (1.1%)
Table 4: Treatment of Kaposi’s Sarcoma
Table 3: Site of KS Lesions
n=188
Men 76 (40.4%)
Baseline age, years 34 (29-41)
Baseline CD4+ count, cell/µl 73 (26-171)
Continous variables are given as medians (interquartile range).  
Ordinal and discrete variables are given as n(%).  ART, antiretroviral 
therapy.   
Table 1: Patient characteristics at baseline
 The majority of patients (136, 72.3%) were treated with ART.
 55 (29.3%) received chemotherapy
 26 (47.3%) received bleomycin, vincristine, and 
adriamycin. 
 24 (43.6%) received vinblastine monotherapy 
 Of the 45 patients who were never started on ART, 39 
(86.7%) were poor risk (stage T1 and/or S1); 2 were 
transferred out, 13 (30%) died and 27 (63%) were lost to 
follow-up. 
 Out of 55 patients who were treated with chemotherapy, 27 
(49.1%) also received radiotherapy.
 Of the 2 patients who underwent surgery, one received 
chemotherapy and both received radiotherapy.
 Kaposi sarcoma was diagnosed in 214 (1.4%) of approximately 15,000 patients enrolled on HIV care
 Of these, 88% (188/214) clinical charts were reviewed.
 136 (72%) of reviewed patients were started on ART, representing 2.2% of the 6292 patients started on 
ART during the study period.
 Most patients presented with advanced disease; 105 (58%) patients were staged T1S1 at presentation.
 The majority had oral lesions
 Pulmonary KS was suspected in 20%.
 HIV infected individuals with Kaposi Sarcoma and older than 18 years who were enrolled in one of three primary
careART clinics in Khayelitsha, SouthAfrica, between May 2001 and January 2007 were included.
 Database and chart reviews from primary and tertiary care were conducted to describe site of lesion, grading
according to theAIDS Clinical Trials Group classification, treatment, and outcomes.
 Logistic regression was used to model determinants of mortality and disease progression of patients onART.
Table 2: Staging of KS Lesions
n=180 
T0 56 (31.1%)
T1 124 (68.9%)
S0 32 (17.8%)
S1 148 (82.2%)
Table 6: Outcomes of Patients with KS
n=184
Alive and in care 62 (33.7%)
Dead 66 (35.8%)
Lost to Follow-up 47 (25.6%)
Transferred Out 9 (4.9%)
 Ordinal and discrete variables are given as n(%)
 61 (65%) patients improved on treatment whilst 33 (35%) were stationary or progressed.
 More than one third of patients were confirmed dead and more than 25% were lost to follow-up by the end of this study.
Oral 65% Head 41%
Trunk 36% Upper Extremity 34%
Lower Extremity 56%
Table 7: Determinants of Mortality in patients on ART Table 8: Determinants of Disease Progression in patients on ART
 Advanced disease (stage T1 and S1) was significantly associated with mortality and disease progression.
 Addition of chemotherapy to ART was independently associated with a 70% (95% CI, 10-90%) decrease in mortality.
OR 95% CI p OR 95% CI p
Age, years 1.0 (0.9-1.0) 0.234 1.0 (0.9-1.0) 0.766
Male 1.2 (0.6-2.3) 0.691 1.4 (0.5-3.4) 0.521
Baseline CD4 count<50 cell/µl 2.2 (1.1-4.5) 0.029 1.5 (0.6-3.7) 0.348
T1 stage (versus T0 stage) 3.8 (1.6-9.0) 0.003 7.4 (2.4-22.8) <0.001
S1 stage (versus S0 stage) 20.2 (2.6-154.0) 0.004 18.6 (2.2-155.7) 0.007
ART only  1.3 (0.7-2.5) 0.477
Chemotherapy 0.6 (0.3-1.3) 0.230 0.3 (0.1-0.9) 0.027
Radiotherapy 1.0 (0.5-2.1) 0.971 1.2 (0.5-3.1) 0.7
Unadjusted Adjusted
OR 95% CI p OR 95% CI p
Age, years 1.0 (0.9-1.1) 0.698 1.0 (0.9-1.1) 0.850
Male 0.5 (0.2-1.2) 0.105 0.5 (0.2-1.8) 0.332
Baseline CD4 count<50 cell/µl 1.6 (0.6-4.1) 0.327 1.1 (0.3-3.5) 0.872
T1 stage (versus T0 stage) 10.3 (1.3-81.8) 0.028 20.7 (2.0-213.7) 0.011
S1 stage (versus S0 stage) 10.3 (1.3-81.8) 0.028 10.1 (1.1-89.2) 0.037
ART only  1.8 (0.7-5.0) 0.250
Chemotherapy 0.8 (0.3-1.9) 0.591 0.4 (0.1-1.3) 0.129
Radiotherapy 0.7 (0.3-1.7) 0.400 0.7 (0.2-2.0) 0.479
Unadjusted Adjusted
ART, antiretroviral therapy.
Methods
 Kaposi Sarcoma (KS) is the most common HIV-related malignancy and is associated with a fourfold increase in
mortality of patients on antiretroviral therapy (ART) in Khayelitsha. Little is known about the evolution of KS on
ART in poor resource settings.
 Khayelitsha Township is situated 30 km from the city of Cape Town and has a population of more than 500,000, of
which the majority lives in informal housing, is very poor and unemployed.
 Prevalence of HIV in adults is 33% and incidence of tuberculosis is above 1600/100,000 per year, one of the highest
in the world.
 Delivery ofART at primary care was initiated by MSF in 2001, in collaboration with Provincial health authorities.
 All patients are initiated on a standardized first line regimen of stavudine, lamivudine, and nevirapine. In case of
contra-indications zidovudine, tenofovir, and efavirenz can be used. The standard second-line regimen is
zidovudine, didanosine, and lopinavir/ritonavir.
 Kaposi Sarcoma is an indication for rapid initiation on ART; patients with stage T1 and/or S1 are referred to tertiary
hospital for assessment of need for chemo- and/or radiotherapy.
 The objectives of this study were to describe baseline characteristics, management, outcomes and determinants of
mortality and disease progression of patients with Kaposi Sarcoma.

Determinants of Mortality and Disease Progression of Kaposi Sarcoma in a Primary care ART Programme in Khayelitsha, South Africa

Determinants of Mortality and Disease Progression of Kaposi Sarcoma in a Primary care ART Programme in Khayelitsha, South Africa

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