Abstract
Today AIDS-related non-Hodgkin's lymphoma (AR-NHL) is a significant cause of morbidity and mortality in HIV-infected patients the world over, and especially in sub-Saharan Africa. While the overall incidence of AR-NHL since the emergence of combination antiretroviral therapy (cART) era has declined, the occurrence of this disease appears to have stabilized. In regions of the world where access to cART is challenging, the impact on disease incidence is less clear. In the resource-rich environment it is clinically well recognized that it is no longer appropriate to consider AR-NHL as a single disease entity and rather treatment of AIDS lymphoma needs to be tailored to lymphoma subtype. While intensive therapeutic strategies in the resource-rich world are clearly improving outcome, in AIDS epicenters of the world and especially in sub-Saharan Africa there is a paucity of data on treatment and outcomes. In fact, only one prospective study of dose-modified oral chemotherapy and limited retrospective studies with sufficient details provide a window into the natural history and clinical management of this disease. The scarcities and challenges of treatment in this setting provide a backdrop to review the current status and realities of the therapeutic approach to AR-NHL in sub-Saharan Africa. More pragmatic and risk-adapted therapeutic approaches are needed.
Highlights
While the advent of combination antiretroviral therapy has had a dramatic effect on the clinical manifestations and progression of HIV disease, reduced the incidence of opportunistic infection(s) and AIDS-related malignancies, and improved overall survival in the resource-rich world, the impact of cART scale-up afforded through World Health Organization (WHO) global initiatives and the President’s Emergency Plan for AIDS Relief (PEPFAR) in improving access and patient monitoring is less apparent in resource challenged AIDS epicenters of the world and especially Africa [1,2,3,4,5,6]
The risk of developing United States (US) Centers for Disease Control AIDS-defining malignancy in HIV-infected subjects is associated with the level of immunodeficiency, especially with Kaposi’s sarcoma and non-Hodgkin’s lymphoma (NHL); the degree of immunosuppression is less apparent for cervical cancer [13, 14]
It is the intent of our review to primarily focus on the clinicopathological presentation and treatment of AIDS-related non-Hodgkin’s lymphoma (AR-NHL) in the resource-limited setting in sub-Saharan Africa
Summary
While the advent of combination antiretroviral therapy (cART) has had a dramatic effect on the clinical manifestations and progression of HIV disease, reduced the incidence of opportunistic infection(s) and AIDS-related malignancies, and improved overall survival in the resource-rich world, the impact of cART scale-up afforded through World Health Organization (WHO) global initiatives and the President’s Emergency Plan for AIDS Relief (PEPFAR) in improving access and patient monitoring is less apparent in resource challenged AIDS epicenters of the world and especially Africa [1,2,3,4,5,6]. There are limited published reviews on the clinicopathological spectrum of lymphoproliferative diseases encountered in sub-Saharan Africa with or without the backdrop of underlying HIV infection and therapeutic outcome, including both prognostic and predictive indicators Often these reviews focus more on the adoption of therapeutic approaches from the developed world that may or may not be suitable for the resource challenged setting in sub-Saharan Africa or report clinical experience in patients that are not HIV-infected [16,17,18,19]. In a review from Cape Town, South Africa less than 2% of 512 consecutively treated lymphoma patients seen at a private sector academic center were HIV-infected [19] Given this backdrop, it is the intent of our review to primarily focus on the clinicopathological presentation and treatment of AIDS-related non-Hodgkin’s lymphoma (AR-NHL) in the resource-limited setting in sub-Saharan Africa. Access to radiation therapy on the continent is even more scarce; and ample pathology diagnostic capability is often very limited and/or nonexistent in some sub-Saharan African nations [26]
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