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Nyirenda M, Ngongondo M, Kang M, Umbleja T, Krown SE, Godfrey C, Samaneka W, Mngqibisa R, Hoagland B, Mwelase N, Caruso S, Martinez-Maza O, Dittmer DP, Borok M, Hosseinipour MC, Campbell TB. Early Progression and Immune Reconstitution Inflammatory Syndrome During Treatment of Mild-To-Moderate Kaposi Sarcoma in Sub-Saharan Africa and South America: Incidence, Long-Term Outcomes, and Effects of Early Chemotherapy. J Acquir Immune Defic Syndr 2020; 84:422-429. [PMID: 32265361 PMCID: PMC7365262 DOI: 10.1097/qai.0000000000002361] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Early progression of AIDS-associated Kaposi sarcoma (KS-PD) and immune reconstitution inflammatory syndrome (KS-IRIS) sometimes occur after the initiation of antiretroviral therapy (ART). METHODS Early KS-PD and KS-IRIS were assessed in the A5264/AMC-067 trial in which participants with mild-to-moderate AIDS-KS were randomized to initiate ART with either immediate or as-needed oral etoposide. Early KS-PD was defined as tumor progression within 12 weeks of ART initiation. When investigators had concern that early KS-PD was KS-IRIS, additional evaluations were performed. Suspected KS-IRIS was defined as early KS-PD accompanied by a CD4 count increase of ≥50 cells per cubic millimeter or plasma HIV-1 RNA decrease of ≥0.5 log10 copies/mL. Clinical outcome was a composite end point categorized as failure, stable, and response at 48 and 96 weeks compared with baseline. RESULTS Fifty of 190 participants had early KS-PD (27%): 28 had KS-IRIS and 22 were not evaluated for KS-IRIS. Early KS-PD and KS-IRIS incidences with immediate etoposide versus ART alone were 16% versus 39%, and 7% versus 21%, respectively. Week 48 clinical outcome was 45% failure, 18% stable, and 37% response for no early KS-PD; 82% failure, 2% stable, and 16% response for early KS-PD; and 88% failure, 0% stable, and 12% response for KS-IRIS. Cumulative incidence of KS tumor response by week 96 was 64% for no early KS-PD, 22% with early KS-PD, and 18% with KS-IRIS. CONCLUSIONS Early KS-PD, including suspected KS-IRIS, was common after starting ART for AIDS-KS and was associated with worse long-term clinical outcomes. Starting ART concurrently with etoposide reduced the incidence of both early KS-PD and KS-IRIS compared with ART alone.
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Affiliation(s)
- Mulinda Nyirenda
- Johns Hopkins Project, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Minhee Kang
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Triin Umbleja
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Catherine Godfrey
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Wadzanai Samaneka
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Rosie Mngqibisa
- Durban International Clinical Research Site, Enhancing Care Foundation, Durban, South Africa
| | - Brenda Hoagland
- Oswaldo Cruz Foundation, Evandro Chagas National Institute of Infectious Diseases, Rio de Janeiro, Brazil
| | | | | | - Oto Martinez-Maza
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA
| | - Dirk P Dittmer
- Department of Microbiology & Immunology, University of North Carolina School of Medicine, and Lineberger Comprehensive Cancer Center, Chapel Hill, NC; and
| | - Margaret Borok
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Mina C Hosseinipour
- UNC Project Malawi, Lilongwe, Malawi
- Department of Microbiology & Immunology, University of North Carolina School of Medicine, and Lineberger Comprehensive Cancer Center, Chapel Hill, NC; and
| | - Thomas B Campbell
- Department of Medicine/Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO
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2
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Dong M, Cioffi G, Wang J, Waite KA, Ostrom QT, Kruchko C, Lathia JD, Rubin JB, Berens ME, Connor J, Barnholtz-Sloan JS. Sex Differences in Cancer Incidence and Survival: A Pan-Cancer Analysis. Cancer Epidemiol Biomarkers Prev 2020; 29:1389-1397. [PMID: 32349967 DOI: 10.1158/1055-9965.epi-20-0036] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/01/2020] [Accepted: 04/24/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Sex plays an important role in the incidence, prognosis, and mortality of cancers, but often is not considered in disease treatment. METHODS We quantified sex differences in cancer incidence using the United States Cancer Statistics (USCS) public use database and sex differences in cancer survival using Surveillance, Epidemiology, and End Results (SEER) public use data from 2001 to 2016. Age-adjusted male-to-female incidence rate ratios (IRR) with 95% confidence intervals (CI) were generated by primary cancer site, race, and age groups. In addition, age-adjusted hazard ratios with 95% CI by sex within site were generated. RESULTS In general, cancer incidence and overall survival were lower in males than females, with Kaposi sarcoma (IRR: 9.751; 95% CI, 9.287-10.242; P < 0.001) having highest male-to-female incidence, and thyroid cancers (HR, 1.774; 95% CI, 1.707-1.845) having largest male-to-female survival difference. Asian or Pacific Islanders had particularly high male-to-female incidence in larynx cancers (IRR: 8.199; 95% CI, 7.203-9.363; P < 0.001), relative to other races. Among primary brain tumors, germ cell tumors had the largest male-to-female incidence (IRR: 3.03; 95% CI, 2.798-3.284, P < 0.001). CONCLUSIONS Overall, incidence and survival of cancer vary significantly by sex, with males generally having lower incidence and survival compared with females. Male-to-female incidence differences were also noted across race and age groups. These results provide strong evidence that the fundamental biology of sex differences affects cancers of all types. IMPACT This study represents the most recent and comprehensive reporting of sex differences in cancer incidence and survival in the United States. Identifying disadvantaged groups is critical as it can provide useful information to improve cancer survival, as well as to better understand the etiology and pathogenesis of specific cancers.
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Affiliation(s)
| | - Gino Cioffi
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Cleveland Center for Health Outcomes Research (CCHOR), Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio.,Central Brain Tumor Registry of the United States (CBTRUS), Hinsdale, Illinois
| | - Jacqueline Wang
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Kristin A Waite
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Cleveland Center for Health Outcomes Research (CCHOR), Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio.,Central Brain Tumor Registry of the United States (CBTRUS), Hinsdale, Illinois
| | - Quinn T Ostrom
- Central Brain Tumor Registry of the United States (CBTRUS), Hinsdale, Illinois.,Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, Texas
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States (CBTRUS), Hinsdale, Illinois
| | - Justin D Lathia
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joshua B Rubin
- Departments of Pediatrics and Neuroscience, Washington University School of Medicine, St. Louis, Missouri
| | - Michael E Berens
- Cancer and Cell Biology Division, Translational Genomics Research Institute (Tgen), Phoenix, Arizona
| | - James Connor
- Department of Neurosurgery, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jill S Barnholtz-Sloan
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio. .,Cleveland Center for Health Outcomes Research (CCHOR), Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio.,Central Brain Tumor Registry of the United States (CBTRUS), Hinsdale, Illinois.,Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Cleveland Institute for Computational Biology, Cleveland, Ohio.,Research Health Analytics and Informatics, University Hospitals Health System (UHHS), Cleveland, Ohio
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3
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Zheng D, Trynda J, Williams C, Vold JA, Nguyen JH, Harnois DM, Bagaria SP, McLaughlin SA, Li Z. Sexual dimorphism in the incidence of human cancers. BMC Cancer 2019; 19:684. [PMID: 31299933 PMCID: PMC6625025 DOI: 10.1186/s12885-019-5902-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 07/02/2019] [Indexed: 02/06/2023] Open
Abstract
Background Sex differences in the incidences of cancers become a critical issue in both cancer research and the development of precision medicine. However, details in these differences have not been well reported. We provide a comprehensive analysis of sexual dimorphism in human cancers. Methods We analyzed four sets of cancer incidence data from the SEER (USA, 1975–2015), from the Cancer Registry at Mayo Clinic (1970–2015), from Sweden (1970–2015), and from the World Cancer Report in 2012. Results We found that all human cancers had statistically significant sexual dimorphism with male dominance in the United States and mostly significant in the Mayo Clinic, Sweden, and the world data, except for thyroid cancer, which is female-dominant. Conclusions Sexual dimorphism is a clear but mostly neglected phenotype for most human cancers regarding the clinical practice of cancer. We expect that our study will facilitate the mechanistic studies of sexual dimorphism in human cancers. We believe that fully addressing the mechanisms of sexual dimorphism in human cancers will greatly benefit current development of individualized precision medicine beginning from the sex-specific diagnosis, prognosis, and treatment. Electronic supplementary material The online version of this article (10.1186/s12885-019-5902-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daoshan Zheng
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road, Griffin 210, Jacksonville, FL, 32224, USA
| | - Justyna Trynda
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road, Griffin 210, Jacksonville, FL, 32224, USA
| | - Cecilia Williams
- KTH Royal Institute of Technology, Karolinska Institutet, Science for Life Laboratory, Stockholm, Sweden
| | - Jeremy A Vold
- Mayo Cancer Registry, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Justin H Nguyen
- Department of Surgery and Mayo Clinic Cancer Center, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Denise M Harnois
- Department of Surgery and Mayo Clinic Cancer Center, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Sanjay P Bagaria
- Department of Surgery and Mayo Clinic Cancer Center, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Sarah A McLaughlin
- Department of Surgery and Mayo Clinic Cancer Center, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Zhaoyu Li
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road, Griffin 210, Jacksonville, FL, 32224, USA.
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4
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Zheng D, Williams C, Vold JA, Nguyen JH, Harnois DM, Bagaria SP, McLaughlin SA, Li Z. Regulation of sex hormone receptors in sexual dimorphism of human cancers. Cancer Lett 2018; 438:24-31. [PMID: 30223066 PMCID: PMC6287770 DOI: 10.1016/j.canlet.2018.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/24/2018] [Accepted: 09/03/2018] [Indexed: 02/07/2023]
Abstract
Gender differences in the incidences of cancers have been found in almost all human cancers. However, the mechanisms that underlie gender disparities in most human cancer types have been under-investigated. Here, we provide a comprehensive overview of potential mechanisms underlying sexual dimorphism of each cancer regarding sex hormone signaling. Fully addressing the mechanisms of sexual dimorphism in human cancers will greatly benefit current development of precision medicine. Our discussions of potential mechanisms underlying sexual dimorphism in each cancer will be instructive for future cancer research on gender disparities.
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Affiliation(s)
- Daoshan Zheng
- Department of Cancer Biology, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Cecilia Williams
- Department of Biosciences and Nutrition, KTH Royal Institute of Technology, Karolinska Institutet, Science for Life Laboratory, Stockholm, Sweden
| | - Jeremy A Vold
- Mayo Cancer Registry, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Justin H Nguyen
- Department of Surgery, and Mayo Clinic Cancer Center, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Denise M Harnois
- Department of Surgery, and Mayo Clinic Cancer Center, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Sanjay P Bagaria
- Department of Surgery, and Mayo Clinic Cancer Center, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Sarah A McLaughlin
- Department of Surgery, and Mayo Clinic Cancer Center, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Zhaoyu Li
- Department of Cancer Biology, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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5
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Evaluation of a Predictive Staging Model for HIV-Associated Kaposi Sarcoma in Uganda. J Acquir Immune Defic Syndr 2017; 74:548-554. [PMID: 28107226 DOI: 10.1097/qai.0000000000001286] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND HIV-associated Kaposi sarcoma (KS) is commonly staged using the AIDS Clinical Trials Group criteria, which classify 3 variables- tumor extent (T), immune status (I), and systemic symptoms (S)-into good risk (0) and poor risk (1). Although validated in the United States and Europe, these criteria have not been systematically evaluated in sub-Saharan Africa, where the burden of KS is greatest. METHODS We reviewed medical charts of adult patients with HIV-associated KS seen at the Uganda Cancer Institute from 1992 to 2007. Vital status at 2 years after KS diagnosis was determined from the medical chart, or by contacting the patient or next of kin. Survival estimates used Kaplan-Meier methods. Predictors were evaluated for 2 periods: 0-4 months and 4-24 months after diagnosis. RESULTS At 2 years after diagnosis, 167 (41%) patients were alive, 156 (39%) had died, and 81 (20%) were lost to follow-up. The Kaplan-Meier estimate of 2-year survival was 57%. S1 was associated with death in months 0-4 [hazard ratio: 6.4, 95% confidence interval: 1.9-21.1], whereas T1 was associated with death in months 4-24 [hazard ratio: 4.0, 95% confidence interval: 1.4 to 11.5]. Immune status was not associated with survival. CONCLUSIONS Systemic symptoms were strongly associated with death in the early period after KS diagnosis, whereas tumor status was most predictive of death in the 4- to 24-month period. These findings suggest that different processes may influence outcomes in early and late periods following KS diagnosis. Further studies are needed to confirm these observations and to identify better predictors of KS survival in sub-Saharan Africa.
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6
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Isaacs T, Abera AB, Muloiwa R, Katz AA, Todd G. Genetic diversity of HHV8 subtypes in South Africa: A5 subtype is associated with extensive disease in AIDS-KS. J Med Virol 2015; 88:292-303. [PMID: 26174882 DOI: 10.1002/jmv.24328] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2015] [Indexed: 01/21/2023]
Abstract
Human herpes virus 8 (HHV8) is the etiological agent of all forms of Kaposi's sarcoma (KS). Six major subtypes (A-F), based on genetic variability of open reading frame (ORF)-K1, have been identified. Numerous studies point to differing tumorigenic and pathogenic properties of the HHV8 subtypes. The study objectives were to determine the HHV8 subtypes and their prevalence in a cohort of clinical and histologically confirmed KS in Cape Town, South Africa, and analyze associations between the different subtypes and clinical presentation of KS. Clinical records were prospectively reviewed to extract clinical presentation; demographic data were retrospectively collected and tissue biopsies were taken for ORF-K1 subtyping. Eighty six patients were subtyped; 81 AIDS (acquired immune deficiency syndrome)-KS and 5 African endemic-KS. Subtype A5 (42/86) and B2 (16/86) predominated. B1, B3, A1 and A4 subtypes were identified in 10/86, 9/86, 4/86 and 1/86 patients, respectively. A5 and B subtypes were found in African blacks and individuals of mixed ancestry, while subtypes A1 and A4 were found only in whites and individuals of mixed ancestry. Subtype A5 was associated with >10 KS lesions at presentation in the AIDS cohort (adjusted OR: 3.13; CI: 1.02-9.58). Subtypes A1 and A4 combined were less likely to be associated with poor risk tumor extension (P = 0.031) and A1 was associated with lower likelihood of lower limb involvement (P = 0.019). In conclusion, these results indicate that subtype A5 and B predominate in South Africa and A5 may be associated with more extensive disease.
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Affiliation(s)
- Thuraya Isaacs
- Department of Medicine, Division of Dermatology, Groote Schuur Hospital and Faculty of Health Sciences University of Cape Town, Cape Town, South Africa
| | - Aron B Abera
- SAMRC/UCT Receptor Biology Research Unit, Division of Medical Biochemistry and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Rudzani Muloiwa
- Department of Paediatrics, Red Cross Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Arieh A Katz
- SAMRC/UCT Receptor Biology Research Unit, Division of Medical Biochemistry and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Gail Todd
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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7
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Sathekge M, Maes A, Van de Wiele C, Dadachova E. Effect of AIDS on women who have sex-determined health issues. Semin Nucl Med 2015; 44:489-98. [PMID: 25362238 DOI: 10.1053/j.semnuclmed.2014.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Worldwide, women account for a growing percentage of human immunodeficiency virus (HIV)-infected patients and more than half of all HIV infections. For many years, morphologic imaging methods were the main approaches employed to investigate HIV and its complications. However, during the past decade, advancements in PET and SPECT imaging technologies opened new possibilities for improved understanding of the pathophysiological processes in HIV. Diagnosis of early HIV-associated neurocognitive disorders (HAND) is important, as many of its symptoms can be caused by other conditions common to people with HIV/AIDS. Presently, there are no PET and SPECT tracers or combination of markers for HAND, hence novel HAND-specific tracers are needed if nuclear medicine is to play a role in solving the problem of the HAND "epidemic." As both highly active antiretroviral therapy (HAART)-induced lipoatrophy and cardiovascular diseases are characterized by ongoing inflammation, FDG-PET/CT imaging may represent an important imaging technique for better understanding the metabolic risk in HIV-infected women on HAART. HIV-infected women are at increased risk for the development of human papilloma virus-associated neoplasms such as cervical and anal carcinomas; these aggressive tumors could be treated better with integration of FDG-PET as part of the standard pretreatment workup. A similar value of FDG-PET may be realized in women with HIV-associated Kaposi sarcoma, as they have more extensive cutaneous disease than men do. In the era of HAART, the incidence and local invasiveness of breast cancer may change, thus creating a need to redefine the pathophysiology of breast cancer in HIV-positive women. Finally, mammary tuberculosis, occasionally the presenting symptom in HIV-infected women, may present with nonspecific clinical, radiological, and histologic findings. In these women, FDG-PET can be of value to detect the lesion for a representative biopsy, staging to exclude pulmonary and other extrapulmonary lesions, and also for therapy monitoring.
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Affiliation(s)
- Mike Sathekge
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa.
| | - Alex Maes
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa; Department of Nuclear Medicine, AZ Groeninge, Kortrijk, Belgium; Department of Morphology and Medical Imaging, University Hospital Leuven, Leuven, Belgium
| | - Christophe Van de Wiele
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa; Department of Nuclear Medicine and Radiology, University of Ghent, Ghent, Belgium
| | - Ekaterina Dadachova
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa; Department of Radiology, Albert Einstein College of Medicine, Bronx, NY
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8
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Excellent clinical outcomes and retention in care for adults with HIV-associated Kaposi sarcoma treated with systemic chemotherapy and integrated antiretroviral therapy in rural Malawi. J Int AIDS Soc 2015; 18:19929. [PMID: 26028156 PMCID: PMC4450240 DOI: 10.7448/ias.18.1.19929] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 04/02/2015] [Accepted: 04/22/2015] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION HIV-associated Kaposi sarcoma (HIV-KS) is the most common cancer in Malawi. In 2008, the non-governmental organization, Partners In Health, and the Ministry of Health established the Neno Kaposi Sarcoma Clinic (NKSC) to treat HIV-KS in rural Neno district. We aimed to evaluate 12-month clinical outcomes and retention in care for HIV-KS patients in the NKSC, and to describe our implementation model, which featured protocol-guided chemotherapy, integrated antiretroviral therapy (ART) and psychosocial support delivered by community health workers. METHODS We conducted a retrospective cohort study using routine clinical data from 114 adult HIV-KS patients who received ART and ≥1 chemotherapy cycle in the NKSC between March 2008 and February 2012. RESULTS At enrolment 97% of patients (n/N=103/106) had advanced HIV-KS (stage T1). Most patients were male (n/N=85/114, 75%) with median age 36 years (interquartile range, IQR: 29-42). Patients started ART a median of 77 days prior to chemotherapy (IQR: 36-252), with 97% (n/N=105/108) receiving nevirapine/lamivudine/stavudine. Following standardized protocols, we treated 20 patients (18%) with first-line paclitaxel and 94 patients (82%) with bleomycin plus vincristine (BV). Of the 94 BV patients, 24 (26%) failed to respond to BV requiring change to second-line paclitaxel. A Division of AIDS grade 3/4 adverse event occurred in 29% of patients (n/N=30/102). Neutropenia was the most common grade 3/4 event (n/N=17/102, 17%). Twelve months after chemotherapy initiation, 83% of patients (95% CI: 74-89%) were alive, including 88 (77%) retained in care. Overall survival (OS) at 12 months did not differ by initial chemotherapy regimen (p=0.6). Among patients with T1 disease, low body mass index (BMI) (adjusted hazard ratio, aHR=4.10, 95% CI: 1.06-15.89) and 1 g/dL decrease in baseline haemoglobin (aHR=1.52, 95% CI: 1.03-2.25) were associated with increased death or loss to follow-up at 12 months. CONCLUSIONS The NKSC model resulted in infrequent adverse events, low loss to follow-up and excellent OS. Our results suggest it is safe, effective and feasible to provide standard-of-care chemotherapy regimens from the developed world, integrated with ART, to treat HIV-KS in rural Malawi. Baseline BMI and haemoglobin may represent important patient characteristics associated with HIV-KS survival in rural sub-Saharan Africa.
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9
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Bohlius J, Valeri F, Maskew M, Prozesky H, Garone D, Sengayi M, Fox MP, Davies MA, Egger M. Kaposi's Sarcoma in HIV-infected patients in South Africa: Multicohort study in the antiretroviral therapy era. Int J Cancer 2014; 135:2644-52. [PMID: 24729433 DOI: 10.1002/ijc.28894] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 03/07/2014] [Accepted: 03/13/2014] [Indexed: 12/13/2022]
Abstract
The incidence of Kaposi's Sarcoma (KS) is high in South Africa but the impact of antiretroviral therapy (ART) is not well defined. We examined incidence and survival of KS in HIV-infected patients enrolled in South African ART programs. We analyzed data of three ART programs: Khayelitsha township and Tygerberg Hospital programs in Cape Town and Themba Lethu program in Johannesburg. We included patients aged >16 years. ART was defined as a regimen of at least three drugs. We estimated incidence rates of KS for patients on ART and not on ART. We calculated Cox models adjusted for age, sex and time-updated CD4 cell counts and HIV-1 RNA. A total of 18,254 patients (median age 34.5 years, 64% female, median CD4 cell count at enrolment 105 cells/μL) were included. During 37,488 person-years follow-up 162 patients developed KS. The incidence was 1,682/100,000 person-years (95% confidence interval [CI] 1,406-2,011) among patients not receiving ART and 138/100,000 person-years (95% CI 102-187) among patients on ART. The adjusted hazard ratio comparing time on ART with time not on ART was 0.19 (95% CI 0.13-0.28). Low CD4 cell counts (time-updated) and male sex were also associated with KS. Estimated survival of KS patients at one year was 72.2% (95% CI 64.9-80.2) and higher in men than in women. The incidence of KS is substantially lower on ART than not on ART. Timely initiation of ART is essential to prevent KS and KS-associated morbidity and mortality in South Africa and other regions in Africa with a high burden of HIV.
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Affiliation(s)
- Julia Bohlius
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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10
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Phipps W, Saracino M, Selke S, Huang ML, Jaoko W, Mandaliya K, Wald A, Casper C, McClelland RS. Oral HHV-8 replication among women in Mombasa, Kenya. J Med Virol 2014; 86:1759-65. [PMID: 24692069 DOI: 10.1002/jmv.23941] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2014] [Indexed: 01/08/2023]
Abstract
Human herpesvirus-8 (HHV-8) replication in the oropharynx may play an important role in HHV-8 transmission and contribute to the development of Kaposi sarcoma (KS) in some individuals. Studies in the United States and Europe report high rates of HHV-8 DNA detection in saliva of HHV-8 infected men, but little is known about the natural history of HHV-8 among persons in sub-Saharan Africa, where prevalence of HHV-8 infection and KS is greatest. To address this gap, this study evaluated oral HHV-8 replication in a cohort of 40 HHV-8 seropositive Kenyan women. Study clinicians collected daily oral swabs from participants for up to 30 consecutive days, and swab samples were tested for HHV-8 DNA using quantitative, real-time polymerase chain reaction. HHV-8 was detected at least once in 27 (68%) participants, and the overall shedding rate was 23%. On days with HHV-8 detection, mean HHV-8 quantity was 4.5 log10 copies/ml. Among HIV-infected women, CD4 count ≥500 cells/mm(3) versus <500 cells/mm(3) was associated with higher HHV-8 copy number (4.8 log10 copies/ml vs. 3.4 log10 copies/ml; coef 1.2 [95% CI, 0.5-1.9]; P = 0.001) and a higher HHV-8 shedding rate (49% vs.12%; RR, 4.2 [95% CI, 0.8-21.4]; P = 0.08). No other factors were associated with HHV-8 shedding rate or copy number. The study demonstrates high rates and quantity of HHV-8 in the oropharynx of HHV-8 seropositive African women. These findings support the observation that oral replication is an essential feature of HHV-8 infection, with likely implications for HHV-8 transmission and KS pathogenesis.
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Affiliation(s)
- Warren Phipps
- Department of Medicine, University of Washington, Seattle, Washington; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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11
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Oral HIV-Associated Kaposi Sarcoma: A Clinical Study from the Ga-Rankuwa Area, South Africa. AIDS Res Treat 2012; 2012:873171. [PMID: 23008762 PMCID: PMC3447356 DOI: 10.1155/2012/873171] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 07/31/2012] [Accepted: 07/31/2012] [Indexed: 12/19/2022] Open
Abstract
UNLABELLED Background. Kaposi sarcoma (KS) is one of the most common neoplasms diagnosed in HIV-seropositive subjects. Oral involvement is frequent and is associated with a poor prognosis. The aim of this study was to characterize the features of oral HIV-KS in patients from Ga-Rankuwa, South Africa. Methods. All cases with confirmed oral HIV-KS treated at the oral medicine clinic in Ga-Rankuwa from 2004 to 2010 were included in this retrospective study. Differences between males and females with oral HIV-KS in relation to HIV infection status, to oral KS presentation and to survival rates were statistically analysed. Results. Twenty (54%) of the 37 patients in the study were females and 17 (46%) were males. In 21 patients (57%), the initial presentation of HIV-KS was in the mouth. Other than the fact that females presented with larger (≥10 mm) oral KS lesions (P = 0.0004), there were no statistically significant gender differences. Significantly more patients presented with multiple oral HIV-KS lesions than with single lesions (P = 0.0003). Nine patients (24%) developed concomitant facial lymphoedema, and these patients had a significantly lower CD4+ T-cell count (28 cells/mm(3)) compared to the rest of the group (130 cells/mm(3)) (P = 0.01). The average CD4+ T-cell count of the patients who died (64 cells/mm(3)) was significantly lower (P = 0.0004), there were no statistically significant gender differences. Significantly more patients presented with multiple oral HIV-KS lesions than with single lesions (P = 0.016) at the time of oral-KS presentation than of those who survived (166 cells/mm(3)). CONCLUSIONS In Ga-Rankuwa, South Africa where HIV-KS is prevalent, oral KS affects similarly males and females. A low CD4+ T-cell count at the time of oral HIV-KS diagnosis and the development of facial lymphoedema during the course of HIV-KS disease portends a poor prognosis.
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Mosam A, Shaik F, Uldrick TS, Esterhuizen T, Friedland GH, Scadden DT, Aboobaker J, Coovadia HM. A randomized controlled trial of highly active antiretroviral therapy versus highly active antiretroviral therapy and chemotherapy in therapy-naive patients with HIV-associated Kaposi sarcoma in South Africa. J Acquir Immune Defic Syndr 2012; 60:150-7. [PMID: 22395672 DOI: 10.1097/qai.0b013e318251aedd] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The optimal approach to HIV-associated Kaposi sarcoma (HIV-KS) in sub-Saharan Africa is unknown. With large-scale rollout of highly active antiretroviral therapy (HAART) in South Africa, we hypothesized that survival in HIV-KS would improve and administration of chemotherapy in addition to HAART would be feasible and improve KS-specific outcomes. METHODS We conducted a randomized, controlled, open-label trial with intention-to-treat analysis. Treatment-naive patients from King Edward VIII Hospital, Durban, South Africa, a public-sector tertiary referral center, with HIV-KS, but no symptomatic visceral disease or fungating lesions requiring urgent chemotherapy, were randomized to HAART alone or HAART and chemotherapy (CXT). HAART arm received stavudine, lamivudine, and nevirapine (Triomune; CXT arm received Triomune plus bleomycin, doxorubicin, and vincristine every 3 weeks. When bleomycin, doxorubicin, and vincristine were not available, oral etoposide (50-100 mg for 1-21 days of a 28-day cycle) was substituted. Primary outcome was overall KS response using AIDS Clinical Trial Group criteria 12 months after HAART initiation. Secondary comparisons included time to response, progression-free survival, overall survival, adverse events, HIV control, CD4 reconstitution, adherence, and quality of life. RESULTS Fifty-nine subjects were randomized to HAART and 53 to CXT; 12-month overall KS response was 39% in the HAART arm and 66% in the CXT arm (difference, 27%; 95% confidence interval, 9%-43%; P = 0.005). At 12 months, 77% were alive (no survival difference between arms; P = 0.49), 82% had HIV viral load <50 copies per milliliter without difference between the arms (P = 0.47); CD4 counts and quality-of-life measures improved in all patients. CONCLUSIONS HAART with chemotherapy produced higher overall KS response over 12 months, whereas HAART alone provided similar improvement in survival and select measures of morbidity. In Africa, with high prevalence of HIV and human herpes virus-8 and limited resources, HAART alone provides important benefit in patients with HIV-KS.
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Affiliation(s)
- Anisa Mosam
- Department of Dermatology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
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Ibekwe P, Ogunbiyi O, Ogun G, George O. Kaposi's sarcoma in HIV-infected women and men in Nigeria. AIDS Patient Care STDS 2011; 25:635-7. [PMID: 21967494 DOI: 10.1089/apc.2011.0122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract Kaposi's sarcoma (KS) in women with HIV infection is observed to have increased from recent studies. To understand the gender-related differences of AIDS-KS in Nigeria, we conducted a prospective study of the clinical, virologic, and immunologic features of newly diagnosed AIDS-KS patients. Prevalence was similar in both genders. There were differences in the distribution of the lesions and the CD4 count in women was significantly lower.
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Affiliation(s)
- P.U. Ibekwe
- University College Hospital Ibadan, Ibadan, Nigeria
| | | | - G.O. Ogun
- University College Hospital Ibadan, Ibadan, Nigeria
| | - O.A. George
- University College Hospital Ibadan, Ibadan, Nigeria
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Phipps W, Ssewankambo F, Nguyen H, Saracino M, Wald A, Corey L, Orem J, Kambugu A, Casper C. Gender differences in clinical presentation and outcomes of epidemic Kaposi sarcoma in Uganda. PLoS One 2010; 5:e13936. [PMID: 21103057 PMCID: PMC2980479 DOI: 10.1371/journal.pone.0013936] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 08/29/2010] [Indexed: 11/18/2022] Open
Abstract
Introduction The incidence of Kaposi sarcoma (KS) has increased dramatically among women in sub-Saharan Africa since the onset of the HIV pandemic, but data on KS disease in women are limited. To identify gender-related differences in KS presentation and outcomes, we evaluated the clinical manifestations and response in men and women with AIDS-associated KS in Uganda. Methods and Findings HIV-infected adults with KS attending the Infectious Diseases Institute (IDI) and Uganda Cancer Institute (UCI) in Kampala, Uganda between 2004 and 2006 were included in a retrospective cohort. Evaluation of KS presentation was based on the clinical features described at the initial KS visit. Response was evaluated as the time to “improvement”, as defined by any decrease in lesion size, lesion number, or edema. The cohort consisted of 197 adults with HIV and KS: 55% (108/197) were women. At presentation, the median CD4 T-cell count was significantly lower in women (58 cells/mm3; IQR 11–156 cells/mm3) than men (124 cells/mm3; IQR 22–254 cells/mm3) (p = 0.02). Women were more likely than men to present with lesions of the face (OR 2.8, 95% CI, 1.4, 5.7; p = 0.005) and hard palate (OR 2.0, 95% CI, 1.1, 3.7; p = 0.02), and were less likely than men to have lower extremity lesions (OR 0.54, 95% CI, 0.3, 0.99; p = 0.05). Women were less likely than men to demonstrate clinical improvement (HR = 0.52, CI 0.31, 0.88; p = 0.01) in multivariate analysis. Conclusions The clinical presentation and response of KS differs between men and women in Uganda. These data suggest that gender affects the pathophysiology of KS, which may have implications for the prevention, diagnosis, and treatment of KS in both men and women. Prospective studies are needed to identify predictors of response and evaluate efficacy of treatment in women with KS, particularly in Africa where the disease burden is greatest.
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Affiliation(s)
- Warren Phipps
- Department of Medicine, University of Washington, Seattle, Washington, United States of America.
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Agaba PA, Sule HM, Ojoh RO, Hassan Z, Apena L, Mu'azu MA, Badung B, Agbaji OO, Idoko JA, Kanki P. Presentation and survival of patients with AIDS-related Kaposi's sarcoma in Jos, Nigeria. Int J STD AIDS 2009; 20:410-3. [PMID: 19451327 DOI: 10.1258/ijsa.2008.008353] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIDS-related Kaposi's sarcoma (AIDS-KS) remains a significant cause of morbidity and mortality. We describe the pattern of presentation and survival in Jos, Nigeria. We identified 48 HIV-positive patients with AIDS-KS and matched them for age and sex with an equal number of HIV-positive patients without AIDS-KS. We compared their clinical, immunological, virological characteristics and survival. They were similar in age and body mass index profile but patients with AIDS-KS had more tuberculosis co-infection (P, 0.02), lower median CD4 count (P, 0.003) and higher mortality (P, 0.002). Surprisingly, patients with AIDS-KS had lower levels of median viral load (29,347 copies/mL) compared with controls (80,533 copies/mL). We recommend specific AIDS-KS therapy in addition to highly active antiretroviral therapy in order to improve survival.
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Affiliation(s)
- P A Agaba
- AIDS Prevention Initiative Nigeria (APIN) Centre, Jos University Teaching Hospital, Jos, Plateau State, Nigeria.
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Mosam A, Hurkchand HP, Cassol E, Page T, Cassol S, Bodasing U, Aboobaker J, Dawood H, Friedland GH, Coovadia HM. Characteristics of HIV-1-associated Kaposi's sarcoma among women and men in South Africa. Int J STD AIDS 2008; 19:400-5. [PMID: 18595878 DOI: 10.1258/ijsa.2008.007301] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Despite the increase of HIV-1-associated Kaposi's sarcoma (KS), little is known about HIV-associated KS in the African setting, particularly among women. A descriptive study of the demographic, clinical, immunological and virological features of AIDS-associated KS from KwaZulu-Natal, South Africa was undertaken. Consecutively, recruited patients were clinically staged; CD4/CD8 cell counts, HIV-1 viral loads and clinical parameters were evaluated. Of the 152 patients (77 male and 75 female) 99% were black. Females were significantly younger (P = 0.02) and had poorer disease prognosis (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.4-5.4, P = 0.003) and were more likely to have extensive cutaneous KS when compared with males (OR = 3.1, 95% CI = 1.4-6.7, P = 0.003). One-third of patients had coexisting HIV-related disease, most commonly tuberculosis, and these were more frequent in females (56.7 vs. 43.3%). In conclusion, HIV-associated KS in South Africans has an equal female-to-male ratio. Females are younger and have more severe disease than males.
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Affiliation(s)
- A Mosam
- Department of Dermatology, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
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Wang J, Stebbing J, Bower M. HIV-Associated Kaposi Sarcoma and Gender. ACTA ACUST UNITED AC 2007; 4:266-73. [DOI: 10.1016/s1550-8579(07)80045-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2007] [Indexed: 12/12/2022]
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Meditz AL, Borok M, MaWhinney S, Gudza I, Ndemera B, Gwanzura L, Campbell TB. Gender Differences in AIDS-Associated Kaposi Sarcoma in Harare, Zimbabwe. J Acquir Immune Defic Syndr 2007; 44:306-8. [PMID: 17146369 DOI: 10.1097/qai.0b013e31802c83d9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Reasons for gender-related differences in the risk of AIDS-related Kaposi sarcoma (AIDS-KS) are unknown. Four hundred thirty-eight male and 166 female AIDS-KS patients were evaluated in Harare, Zimbabwe. Female patients were younger than male patients in this study (median of 33 vs. 38 years; P < 0.001), mirroring the epidemiology of AIDS in Zimbabwe. In a multivariate model adjusted for CD4 T-cell count, age, prior radiation treatment, and chemotherapy, women were more likely to report fever, diaphoresis, or weight loss (odds ratio = 1.7, 95% confidence interval: 1.1 to 2.7; P = 0.009). These findings suggest an increased severity of KS or other unidentified infections among women with AIDS-KS in Zimbabwe.
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Affiliation(s)
- Amie L Meditz
- Division of Infectious Diseases, Department of Medicine, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262, USA
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Umeh OC, Currier JS. Sex differences in HIV: Natural history, pharmacokinetics, and drug toxicity. Curr Infect Dis Rep 2005; 7:73-78. [PMID: 15610674 DOI: 10.1007/s11908-005-0026-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In the early years of the HIV epidemic, the burden of the disease was principally among men. In recent years, HIV infection among women has become a growing problem worldwide. There is now an increasing awareness that HIV may affect men and women differently. New data have emerged from studies that have focused on HIV-infected women, suggesting the existence of sex-related differences in natural history, pharmacokinetics, and toxicity of antiretroviral therapy. This paper reviews the current literature with an emphasis on recent data regarding sex differences in HIV that have implications for clinical practice.
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Affiliation(s)
- Obiamiwe C Umeh
- Center for AIDS Research and Education, David Geffen School of Medicine at UCLA, BH-412 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA.
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Vega L, Montes de Oca P, Saavedra R, Ostrosky-Wegman P. Helper T cell subpopulations from women are more susceptible to the toxic effect of sodium arsenite in vitro. Toxicology 2004; 199:121-8. [PMID: 15147786 DOI: 10.1016/j.tox.2004.02.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/02/2004] [Accepted: 02/05/2004] [Indexed: 11/28/2022]
Abstract
Arsenic is known to produce inhibition as well as induction of proliferative responses in animal and human cells depending on the doses. Despite the amount of information on the immunotoxic effects of arsenic exposure in different animal models, little is known in humans. Arsenic susceptibility of lymphocyte subpopulations (T helper (Th), CD4+; T cytotoxic (Tc), CD8+) and whether arsenic effects are gender related are still to be determined. This work evaluated the in vitro toxicity of sodium arsenite on human T lymphocyte subpopulations from men and women. Peripheral blood mononuclear cells (PBMC) obtained from healthy young men and women were treated with sodium arsenite (0.01, 0.1, and 1 microM). We assessed cell viability, cell proliferation, and the proportion of Th and Tc cells after 48 or 72h of arsenic exposure in resting and phytohemagglutinin M (PHA)-activated PBMC. We observed that sodium arsenite at 1 microM was more toxic for Th than for Tc cells in PBMC from women. Besides, T lymphocytes from women were more affected by the cell proliferation inhibition induced by arsenic, suggesting that women could be more susceptible to the toxic and immunotoxic effects caused by arsenic exposure.
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Affiliation(s)
- Libia Vega
- Sección Externa de Toxicología, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, San Pedro Zacatenco, Apdo. Postal 07000, D.F. 07600, Mexico.
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Gilad J, Walfisch A, Borer A, Schlaeffer F. Gender differences and sex-specific manifestations associated with human immunodeficiency virus infection in women. Eur J Obstet Gynecol Reprod Biol 2003; 109:199-205. [PMID: 12860342 DOI: 10.1016/s0301-2115(03)00048-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The rapidly growing rates of human immunodeficiency virus (HIV) infection among women has prompted many challenging issues related to the management and consequences of HIV and its complications in this population. This paper reviews the current evidence with regard to various aspects of HIV infection in women. Special emphasis is placed on gender-differences as well as sex-specific manifestation of this disease, including epidemiology, viral load determination and disease progression, related morbidity, and anti-retroviral therapy. It is concluded that current advances in the understanding of HIV infection among women may lead to further refinement and optimization efforts in the management of HIV-infected women.
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Affiliation(s)
- Jacob Gilad
- Infectious Disease Institute, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 151, Beer-Sheva 84101, Israel.
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Palacios R, Santos J, Fernández A, Flores MP. [Kaposi sarcoma simulating splenic abscesses in a woman with AIDS]. Enferm Infecc Microbiol Clin 2001; 19:40-1. [PMID: 11256253 DOI: 10.1016/s0213-005x(01)72553-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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