Page 43 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 14 of 26 Guideline

Confusion and other neurological disease in TABLE 4: The association of certain cancers with HIV-1 infection in South Africa,
1995–2004.
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people living with HIV. Cancer site or type Total HIV-1 + Odds ratio (OR, 95% CI, adjusted
(N) (%) for age, sex and year of diagnosis)
Human immunodeficiency virus infects the human brain. Kaposi’s sarcoma 333 89.2 50.4 (34.2–74.3)
This occurs during the first few weeks following acquisition Non-Hodgkin’s 223 44.4 6.1 (4.4–8.4)
of the virus and establishes a chronic but usually low-grade lymphoma
infection which persists for the remainder of the individual’s Squamous cell, skin 70 21.4 2.6 (1.4–4.7)
life. Neurological consequences are frequent but generally Anogenital other 157 22.3 2.5 (1.7–3.8)
than cervix
mild or asymptomatic and usually well controlled with ART. Cervix 1586 14.9 1.7 (1.4–2.0)
If the patient is naïve to ART or if the virus in the CNS has Melanoma 53 15.1 1.6 (0.7–3.5)
become resistant to ART, the function of the brain will be Hodgkin’s lymphoma 154 19.5 1.5 (1.9–2.4)
impaired for example, HIV encephalopathy. The latter is a Source: Stein L, Urban MI, O’Connell D, et al. The spectrum of human immunodeficiency
life-threatening and dementing process characterised by virus-associated cancers in a South African black population: Results from a case-control
study, 1995–2004. Int J Cancer. 2008;122:2260–2265. https://doi.org/10.1002/ijc.23391
motor-slowing, abnormal movement (basal ganglia Note: This table provides odds ratios that define the occurrence of various cancers in HIV-
involvement) and progressive cognitive decline. Human infected people in South African during 1995–2004. All of the cancers represented were
associated with HIV infection rates greater than that of the general South African population
immunodeficiency virus also attacks the peripheral nervous of the time.
system (PNS) and is responsible for a painful symmetric CI, confidence interval.
sensory polyneuropathy that leaves the individual wheelchair Establishing early linkage to care, particularly to palliative
and bedbound and in constant pain. These conditions will
usually respond to viral suppression with ARVs tailored to and HIV care, is essential if the goal of improved survival
treat the CNS infection. Treatment with ARVs is warranted and the relief of suffering is to be reached. However, several
even in the context of palliation. hurdles must be overcome:
• Late presentation. Stigma, misunderstanding and
Several of the following conditions need to be considered in denialism continue as barriers to early detection of HIV
the HIV-infected patient with serious neurological disease, and cancer. Patients present at an advanced HIV stage,
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as detailed in Table 4. naïve to ART, with a low baseline CD4 level and multiple
competing diagnoses.
Management: Treat the cause where identified. Is the patient • Delays in receiving cancer treatment. Large number of
on ART (efavirenz)? TB drugs (Isoniazid)? Is the HIV infection patients, few or inadequately skilled staff, insufficient
controlled in the serum and in the CSF? specialists and unsupportive management cause delay
in treatment. In many instances, patients die before
Suggested end-of-life care: test results return and before a link with oncology and
• Lorazepam for anxiety: 0.25 mg po or IV–2 mg po or IV or radiotherapy is made. Thirty African and Asian countries
S/C every 4–6 h as needed. Increase the dose to 5 mg if have no radiotherapy machines and in many LMICs,
necessary. oncologists, if present, are restricted to the largest cities. 66
• Haloperidol for delirium: 0.5 mg po or IV–1 mg po or IV • Laboratory support. Obtaining reports, for example,
every hour as needed. When symptoms have settled, give biopsy (histology) results, in the public sector in SA is
the daily total dose in 3–4 divided doses through the day. plagued by long delays, while histology reports in the
private sector return within a couple of days, and oncology
HIV, cancer and palliative care in referrals in the public sector cannot be processed without
Southern Africa the confirmatory histology. In the absence of histological
confirmation, patients die while awaiting their test results
Cancer case fatality rates are higher in low-income regions or while awaiting their oncology appointment.
such as Africa (75%) than in high-income regions for example, • HIV and cancer therapy. Chemotherapy in Africa and
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Europe and North America (46%). On the back of this, the SA’s public sector is frequently characterised by the
growing numbers of HIV-infected persons with cancer, a so- ongoing use of drugs that are no longer viewed as optimal
called ‘hidden cancer epidemic’ in LMICs, is of concern. 61,62 in developed regions. Problems include post-
67
More than a decade ago, South African researchers recorded chemotherapy neutropenia, HIV immunosuppression,
the prevalence of several cancers among HIV-infected South antimicrobial resistance, frequent drug stock-outs and
Africans (see Table 5). Odds ratios confirmed a substantial drug–drug interactions between cytochrome P450
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increase in risk among the HIV-infected patients, particularly substrates, inducers and inhibitors, and ARVs.
for the traditional AIDS-defining tumours, and in Africa How can the HIV-infected cancer patient be better served?
these cancers still predominate: Kaposi’s sarcoma, non-
Hodgkin’s lymphoma, cervical carcinoma and CNS • Prevention
lymphoma. The incidence of non-AIDS-defining cancers, ß Tobacco use control
however, in the region (e.g. Hodgkin’s disease, solid tumours ß Hepatitis B vaccination
of the lung, GIT and breast, et cetera) is rising despite the use ß Hepatitis C serology and access to directly acting
of ART. The latter is a global trend and affects PLWHIV 10–15 antivirals (DAAs)
years earlier than their peers with similar tumours. 64,65 ß Human papillomavirus (HPV) vaccination

http://www.sajhivmed.org.za 36 Open Access