Download HIV and cancer in referral hospitals from four West African countries

HIV and cancer in referral hospitals
from four West African countries
The IeDEA West Africa Collaboration
A Jaquet, M Odutola, DK Ekouevi, A Tanon, E Oga, J Akakpo, M Charurat,
DM Zannou, SP Eholie, AJ Sasco, E Bissagnene, C Adebamowo, F Dabis
20th International AIDS Conference, Melbourne, Australia, 23 July 2014
Context
• In sub-Saharan Africa, mortality and morbidity of HIVinfected people are mainly mediated by opportunistic
infections, however:
– With ART scale-up, cancer will soon substantially contribute to
disease burden of Africans with HIV as already observed in highresource countries
– Etiologic factors interacting with HIV infection and leading to the
occurrence of cancers are quite different
• Need to provide an overview of the intersection between
the cancer and the HIV epidemics in sub-Saharan Africa
2
Objective
Estimate the association between HIV infection
and selected types of cancers among patients
hospitalized for a malignant condition in four
West African countries
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Methods (1)
Study design & population (1)
• A case-referent study was initiated in referral hospitals of Côte
d’Ivoire (Abidjan) and Benin (Cotonou) and subsequently
extended to Togo (Lome) and Nigeria (Abuja, Benin City)
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Methods (2)
Study design & population
• During a 12-month period, each participating clinical
ward selected all adult patients seeking care with a
confirmed diagnosis of cancer
– Histological examination systematically proposed (supported by the
project)
– Included patients interviewed to collect socio-demographic (age,
gender, place of living..) & behavioural data (sexual & reproductive
life)
– Systematic HIV testing: Determine® + confirmation (Genie 2®)
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Methods (3)
Analysis
• HIV prevalence reported for selected types of cancer
– AIDS-defining (Kaposi Sarcoma, Non Hodgkin lymphoma & Invasive
cervical cancer)
– A subset of non-AIDS defining cancers (known or suspected to be linked
with HIV infection from previous reports)
• Compared to a referent group of cancers not reported in the
literature to be associated with HIV
– Colorectal, Oesophagus, Gastric, Breast, Ovary, Endometrium, Prostate,
Kidney, Bladder & urinary ducts, Endocrine tumours
• Odds ratio (OR) [95% CI] estimated for these selected cancers
using an unconditional logistic model
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Results (1)
Characteristics of included adult patients according to HIV status
HIV + (n=184) HIV – (n=1,460)
P
Total (N=1,644)
41.5 [35 – 48]
50 [38 – 61]
<10-4
49 [38 – 60]
Women n (%)
127 (69.0)
864 (59.2)
0.01
991 (60.3)
Country n (%)
Benin
Côte d’Ivoire
Nigeria
Togo
184 (100.0)
12 (6.5)
116 (63.0)
46 (25.0)
10 (5.5)
1,460 (100.0)
79 (5.4)
809 (55.4)
513 (35.1)
59 (4.1)
0.07
1,644 (100.0)
91 (5.5)
925 (56.3)
559 (34.0)
69 (4.2)
Age, median [IQR]
Sexual partners* n (%)
0 to 2
2 to 4
5 and over
<10-2
87 (49.4)
49 (27.8)
40 (22.7)
824 (58.5)
393 (27.9)
191 (13.6)
911 (57.5)
442 (27.9)
231 (14.6)
Lifetime number of sexual partners declared (21 missing values)
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Results (2)
HIV negative (n=1,640)
HIV positive (n=184)
Breast
Cervix
Cervix
Kaposi sarcoma
Prostate
NHL*
NHL*
Breast
Leukemia
Ano-genital
Colorectal
Liver
OPL†
Colorectal
Liver
Skin
Ovary
OPL†
0
10
20 (%)
* Non Hodgkin
Lymphoma
† Oral cavity,
larynx, pharynx
0
10
20
30 (%)
Most reported cancer types according to HIV status in participating
referral hospitals (Benin, Côte d’Ivoire, Nigeria and Togo) 8
Results (3)
Association between AIDS defining cancers and HIV infection in participating
referral hospitals (Benin, Côte d’Ivoire, Nigeria and Togo)
Cancer site or morphological type*
Comparison group
HIV infection
Multivariate†
n/N (%)
OR
95% CI
P
Total
35/792 (4.4)
1.0
Women (for cervical cancer)
21/483 (4.3)
1.0
Kaposi sarcoma (M9140)
37/58 (63.8)
32.2
Non Hodgkin lymphoma
(M9591, 9670-9727)
22/133 (16.5)
3.8
2.1 – 6.9
< 10-4
Cervical cancer (C53)
47/258 (18.2)
4.8
2.8 – 8.4
< 10-4
AIDS classifying cancers
* According to International Classification of
Diseases for Oncology, 3rd Edition
16.4 – 63.0 < 10-4
† Adjusted on age, sex and lifetime number
of sexual partners
9
Results (4)
Association between non AIDS defining cancers and HIV infection in participating
referral hospitals (Benin, Côte d’Ivoire, Nigeria and Togo)
Cancer site or morphological type*
Comparison group
HIV infection
Multivariate†
n/N (%)
OR
95% CI
P
Total
35/792 (4.4)
1.0
Women (for cervical cancer)
Non AIDS classifying cancers
21/483 (4.3)
1.0
Anal, Vulvar, Vaginal (C21, C51, C52)
10/25 (40.0)
17.7 6.9 – 45.2 < 10-4
Squamous cell skin cancers
(C44, M8050-8082)
6/29 (20.1)
5.5
2.0 – 15.2 < 10-3
Primary liver cancers (C22)
7/69 (10.1)
2.3
1.0 – 5.8
Hodgkin lymphoma (M9650-9667)
3/23 (13.0)
3.4
0.9 – 13.5 0.08
* According to International Classification of
Diseases for Oncology, 3rd Edition
† Adjusted on age, sex and lifetime number
of sexual partners
10
0.05
Discussion (1)
• AIDS-defining cancers are strongly associated with HIV
infection and are leading causes of cancer in West Africa
• A significant association is now reported between HIV
infection and some Non-AIDS defining cancers including
cancers of the ano-genital organs and squamous cell skin
cancer
• Concordant with previous findings from South Africa based
on the same methodological approach (Stein et al, Int J Cancer 2008)
– Ano-genital cancers: OR=2.2 (95% CI 1.4–3.3)
– Squamous cell skin cancer: OR=2.6 (95% CI 1.4–4.9)
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Discussion (2)
• Association between HIV and primary liver cancer
• Concordant with results reported from linkage studies
in high-resource settings
• Limitations
- Sample size
- No standardized case definition of hepatocarcinoma
- Risk factors such as chronic viral hepatitis not recorded
• Need to conduct dedicated case-control studies
• Ongoing project: “HIV and hepatocarcinoma in Benin,
Côte d’Ivoire, Mali & Togo”
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Conclusions
• The study provided a rather representative and precise
picture of the association between AIDS-defining cancers
and HIV infection in West Africa
• HPV-related cancers including cervical cancer but also anogenital cancer and squamous cell skin cancer are reported
here as leading causes of malignancies in people living with
HIV
• As these cancers are amenable to prevention strategies,
screening of HPV-related cancers among persons living with
HIV is of paramount importance in West Africa
13
Acknowledgments
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All patients & medical staff that participated to the cancer studies
HIV & Cancer studies coordinators & investigators
Bordeaux: E Balestre, A Sasco
Benin: J Akakpo, J Sehonou, DM Zannou
Côte d’Ivoire: A Tanon, A. Attia, SP Eholie
Nigeria: E Oga, M Odutola, E Jedy-Agba, M Charurat, C
Adebamowo
Togo: DK Ekouevi, B Goilibe
PACCI regional center for data management : T.A. Azani, P Coffie &
colleagues
IeDEA WA PIs: E Bissagnene, F Dabis
Funding
The National Cancer Institute (NCI), the Eunice Kennedy Shriver National
Institute of Child Health & Human Development (NICHD) and the National
Institute of Allergy and Infectious Diseases (NIAID) of the U.S. National Institutes
of Health (NIH), as part of the International Epidemiologic Databases to Evaluate
AIDS (IeDEA) under Award Number U01AI069919.