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Collier SM, Semeere A, Chemtai L, Byakwaga H, Lagat C, Laker-Oketta M, Bramante J, Pacheco A, Zehtab M, Strahan AG, Grant M, Bogart LM, Bassett IV, Busakhala N, Opakas J, Maurer T, Martin J, Kiprono S, Freeman EE. Impact of a multicomponent navigation strategy on stigma among people living with HIV and Kaposi's sarcoma in Kenya: a qualitative analysis. J Natl Cancer Inst Monogr 2024; 2024:38-44. [PMID: 38836529 DOI: 10.1093/jncimonographs/lgae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/26/2023] [Accepted: 02/26/2024] [Indexed: 06/06/2024] Open
Abstract
Persons with HIV-associated Kaposi's sarcoma (KS) experience three co-existing stigmatizing health conditions: skin disease, HIV, and cancer, which contribute to a complex experience of stigmatization and to delays in diagnosis and treatment. Despite the importance of stigma among these patients, there are few proven stigma-reduction strategies for HIV-associated malignancies. Using qualitative methods, we explore how people with HIV-associated KS in western Kenya between August 2022 and 2023 describe changes in their stigma experience after participation in a multicomponent navigation strategy, which included 1) physical navigation and care coordination, 2) video-based education with motivational survivor stories, 3) travel stipend, 4) health insurance enrollment assistance, 5) health insurance stipend, and 6) peer mentorship. A purposive sample of persons at different stages of chemotherapy treatment were invited to participate. Participants described how a multicomponent navigation strategy contributed to increased knowledge and awareness, a sense of belonging, hope to survive, encouragement, and social support, which served as stigma mitigators, likely counteracting the major drivers of intersectional stigma in HIV-associated KS.
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Affiliation(s)
- Sigrid M Collier
- Department of Dermatology, University of Washington, Seattle, WA, USA
- Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Aggrey Semeere
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Linda Chemtai
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Helen Byakwaga
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Celestine Lagat
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | - Juliet Bramante
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Ann Pacheco
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Morvarid Zehtab
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexis G Strahan
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Merridy Grant
- Western Australian Centre for Rural Health, University of Western, Australia
| | - Laura M Bogart
- RAND Corporation, Santa Monica, CA, USA
- Department of Psychiatry, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Ingrid V Bassett
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Naftali Busakhala
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Pharmacology and Toxicology, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Jesse Opakas
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Toby Maurer
- Department of Dermatology, Indiana University, Indianapolis, IN, USA
| | - Jeffrey Martin
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Samson Kiprono
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Esther E Freeman
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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2
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Suneja G, Kimani SM, Gill H, Painschab MS, Knettel BA, Watt MH. Addressing the Intersectional Stigma of Kaposi Sarcoma and HIV: A Call to Action. JCO Glob Oncol 2024; 10:e2300264. [PMID: 38301182 PMCID: PMC10846783 DOI: 10.1200/go.23.00264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 02/03/2024] Open
Affiliation(s)
- Gita Suneja
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
- Department of Radiation Oncology, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT
| | - Stephen M. Kimani
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
- Division of Oncology, Department of Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT
| | - Hailie Gill
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT
| | - Matthew S. Painschab
- Division of Hematology, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
- UNC Project Malawi, Lilongwe, Malawi
| | - Brandon A. Knettel
- School of Nursing, Duke University, Durham, NC
- Duke Global Health Institute, Duke University, Durham, NC
| | - Melissa H. Watt
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT
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3
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Tibenderana RM, Blumenthal MJ, Bukajumbe E, Schäfer G, Mohamed Z. Clinical Significance of Elevated KSHV Viral Load in HIV-Related Kaposi's Sarcoma Patients in South Africa. Viruses 2024; 16:189. [PMID: 38399965 PMCID: PMC10893554 DOI: 10.3390/v16020189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/12/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
Kaposi's sarcoma (KS) is an AIDS-defining illness caused by Kaposi's sarcoma-associated herpesvirus (KSHV) predominantly in the context of HIV-related immune suppression. We aimed to explore the usefulness of KSHV DNA viral load (VL) measurement in predicting the severity, response to treatment and outcome of KS. We retrospectively assessed a cohort of KS patients (n = 94) receiving treatment at Groote Schuur Hospital, Cape Town, South Africa. Demographic and clinical data, KS staging and response to treatment were extracted from patient files, while long-term survival was ascertained from hospital records. KSHV serology and VL and hIL-6 were determined empirically from patients' blood. All patients were HIV-positive adults, the majority of whom were on HAART at the time of recruitment. KSHV VL was detectable in 65 patients' blood (median: 280.5/106 cells (IQR: 69.7-1727.3)) and was highest in patients with S1 HIV-related systemic disease (median 1066.9/106 cells, IQR: 70.5-11,269.6). KSHV VL was associated with the S1 stage in a binomial regression controlling for confounders (adjusted odds ratio 5.55, 95% CI: 1.28-24.14, p = 0.022). A subset of six patients identified to have extremely high KSHV VLs was predominantly T1 stage with pulmonary KS, and most had died at follow-up. In our cohort, elevated KSHV VL is associated with systemic HIV-related illness in KS disease. Extremely high KSHV VLs warrant further investigation for patients potentially requiring intensive treatment and investigation for progression or diagnosis of concurrent KSHV lytic syndromes.
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Affiliation(s)
| | - Melissa Jayne Blumenthal
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa;
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town 7925, South Africa
| | - Emmanuel Bukajumbe
- Aberdeen Surgery, Aberdeen, NSW 2336, Australia;
- Hatchile Consult Ltd., Kampala 759125, Uganda
| | - Georgia Schäfer
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa;
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town 7925, South Africa
| | - Zainab Mohamed
- Department of Radiation Oncology, University of Cape Town, Cape Town 7925, South Africa;
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4
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Moorad R, Kasonkanji E, Gumulira J, Gondwe Y, Dewey M, Pan Y, Peng A, Pluta LJ, Kudowa E, Nyasosela R, Tomoka T, Tweya H, Heller T, Gugsa S, Phiri S, Moore DT, Damania B, Painschab M, Hosseinipour MC, Dittmer DP. A prospective cohort study identifies two types of HIV+ Kaposi Sarcoma lesions: proliferative and inflammatory. Int J Cancer 2023; 153:2082-2092. [PMID: 37602960 PMCID: PMC11074775 DOI: 10.1002/ijc.34689] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/15/2023] [Accepted: 06/29/2023] [Indexed: 08/22/2023]
Abstract
Kaposi sarcoma (KS) is the most common cancer in people living with HIV (PLWH) in many countries where KS-associated herpesvirus is endemic. Treatment has changed little in 20 years, but the disease presentation has. This prospective cohort study enrolled 122 human immunodeficiency virus (HIV) positive KS patients between 2017 and 2019 in Malawi. Participants were treated with bleomycin, vincristine and combination antiretroviral therapy, the local standard of care. One-year overall survival was 61%, and progression-free survival was 58%. The 48-week complete response rate was 35%. RNAseq (n = 78) differentiated two types of KS lesions, those with marked endothelial characteristics and those enriched in inflammatory transcripts. This suggests that different KS lesions are in different disease states consistent with the known heterogeneous clinical response to treatment. In contrast to earlier cohorts, the plasma HIV viral load of KS patients in our study was highly variable. A total of 25% of participants had no detectable HIV; all had detectable KSHV viral load. Our study affirms that many KS cases today develop in PLWH with well-controlled HIV infection and that different KS lesions have differing molecular compositions. Further studies are needed to develop predictive biomarkers for this disease.
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Affiliation(s)
- Razia Moorad
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Department of Immunology and Microbiology, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | | | | | | | | | - Yue Pan
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Department of Biostatistics, The University of North Carolina at Chapel Hill; Chapel Hill
| | - Alice Peng
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | - Linda J. Pluta
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | - Evaristar Kudowa
- Department of Immunology and Microbiology, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | | | | | | | | | | | | | - Dominic T Moore
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | - Blossom Damania
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Department of Immunology and Microbiology, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | - Matthew Painschab
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- UNC Project Malawi, Lilongwe, Malawi
| | - Mina C. Hosseinipour
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- UNC Project Malawi, Lilongwe, Malawi
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill; Chapel Hill, USA
| | - Dirk P. Dittmer
- Lineberger Comprehensive Cancer Centre, School of Medicine, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Department of Immunology and Microbiology, University of North Carolina at Chapel Hill; Chapel Hill, USA
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill; Chapel Hill, USA
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5
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Nolan DJ, Rose R, Zhang R, Leong A, Fogel GB, Scholte LLS, Bethony JM, Bracci P, Lamers SL, McGrath MS. The Persistence of HIV Diversity, Transcription, and Nef Protein in Kaposi's Sarcoma Tumors during Antiretroviral Therapy. Viruses 2022; 14:v14122774. [PMID: 36560778 PMCID: PMC9782636 DOI: 10.3390/v14122774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/05/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Epidemic Kaposi's sarcoma (KS), defined by co-infection with Human Herpes Virus 8 (HHV-8) and the Human Immunodeficiency Virus (HIV), is a major cause of mortality in sub-Saharan Africa. Antiretroviral therapy (ART) significantly reduces the risk of developing KS, and for those with KS, tumors frequently resolve with ART alone. However, for unknown reasons, a significant number of KS cases do not resolve and can progress to death. To explore how HIV responds to ART in the KS tumor microenvironment, we sequenced HIV env-nef found in DNA and RNA isolated from plasma, peripheral blood mononuclear cells, and tumor biopsies, before and after ART, in four Ugandan study participants who had unresponsive or progressive KS after 180-250 days of ART. We performed immunohistochemistry experiments to detect viral proteins in matched formalin-fixed tumor biopsies. Our sequencing results showed that HIV diversity and RNA expression in KS tumors are maintained after ART, despite undetectable plasma viral loads. The presence of spliced HIV transcripts in KS tumors after ART was consistent with a transcriptionally active viral reservoir. Immunohistochemistry staining found colocalization of HIV Nef protein and tissue-resident macrophages in the KS tumors. Overall, our results demonstrated that even after ART reduced plasma HIV viral load to undetectable levels and restored immune function, HIV in KS tumors continues to be transcriptionally and translationally active, which could influence tumor maintenance and progression.
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Affiliation(s)
- David J. Nolan
- Bioinfoexperts, LLC, Thibodaux, LA 70301, USA
- Correspondence:
| | | | - Rongzhen Zhang
- Departments of Laboratory Medicine, Pathology and Medicine, The University of California at San Francisco, San Francisco, CA 94110, USA
| | - Alan Leong
- Departments of Laboratory Medicine, Pathology and Medicine, The University of California at San Francisco, San Francisco, CA 94110, USA
| | | | - Larissa L. S. Scholte
- Department of Microbiology, Immunology and Tropical Medicine, The George Washington University, Washington, DC 20037, USA
| | - Jeffrey M. Bethony
- Department of Microbiology, Immunology and Tropical Medicine, The George Washington University, Washington, DC 20037, USA
| | - Paige Bracci
- The AIDS and Cancer Specimen Resource, San Francisco, CA 94110, USA
| | | | - Michael S. McGrath
- Departments of Laboratory Medicine, Pathology and Medicine, The University of California at San Francisco, San Francisco, CA 94110, USA
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Freeman EE, McCann NC, Semeere A, Reddy KP, Laker-Oketta M, Byakwaga H, Pei PP, Hajny Fernandez ME, Kiprono S, Busakhala N, Martin JN, Maurer T, Bassett IV, Freedberg KA, Hyle EP. Evaluation of four chemotherapy regimens for treatment of advanced AIDS-associated Kaposi sarcoma in Kenya: a cost-effectiveness analysis. Lancet Glob Health 2022; 10:e1179-e1188. [PMID: 35839816 PMCID: PMC9287596 DOI: 10.1016/s2214-109x(22)00242-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND The most effective treatment for advanced AIDS-associated Kaposi sarcoma is paclitaxel or pegylated liposomal doxorubicin (PLD); neither is routinely used in sub-Saharan Africa due to limited availability and high cost. We examined the clinical impact, costs, and cost-effectiveness of paclitaxel or PLD in Kenya, compared with etoposide or bleomycin-vincristine. METHODS In this study, we use the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-International Model to project clinical outcomes and costs among people living with HIV and advanced Kaposi sarcoma on antiretroviral therapy. We compared four different treatment strategies: etoposide, bleomycin-vincristine, paclitaxel, or PLD. We derived cohort characteristics and costs from the Kenyan Academic Model for Providing Access to Healthcare network, and adverse events, efficacy, and mortality from clinical trials. We projected model outcomes over a lifetime and included life expectancy, per-person lifetime costs, and incremental cost-effectiveness ratios (ICERs). We conducted budget impact analysis for 5-year total costs and did deterministic and probabilistic sensitivity analyses to evaluate the effect of uncertainty in input parameters. FINDINGS We found that paclitaxel would be more effective than bleomycin-vincristine and would increase life expectancy by 4·2 years per person. PLD would further increase life expectancy by 0·6 years per person. Paclitaxel would be the most cost-effective strategy (ICER US$380 per year-of-life-saved compared with bleomycin-vincristine) and would remain cost-effective across a range of scenarios. PLD would be cost-effective compared with paclitaxel if its price were reduced to $100 per cycle (base case $180 per cycle). Implementing paclitaxel instead of bleomycin-vincristine would save approximately 6400 life-years and would increase the overall 5-year Kenyan health-care costs by $3·7 million; increased costs would be primarily related to ongoing HIV care given improved survival. INTERPRETATION Paclitaxel would substantially increase life expectancy and be cost-effective compared with bleomycin-vincristine for advanced AIDS-associated Kaposi sarcoma in Kenya and should be the standard of care. PLD would further improve survival and be cost-effective with a 44% price reduction. FUNDING US National Institutes of Health and Massachusetts General Hospital. TRANSLATION For the Swahili translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Esther E Freeman
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA.
| | - Nicole C McCann
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Aggrey Semeere
- Infectious Diseases Institute, Kampala, Uganda; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Krishna P Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | | | | | - Pamela P Pei
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Samson Kiprono
- Department of Internal Medicine, Moi University School of Medicine, Eldoret, Kenya
| | - Naftali Busakhala
- Department of Internal Medicine, Moi University School of Medicine, Eldoret, Kenya; Department of Pharmacology and Toxicology, Moi University School of Medicine, Eldoret, Kenya
| | - Jeffery N Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Toby Maurer
- Department of Dermatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ingrid V Bassett
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA; Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Emily P Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA; Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
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7
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McMahon DE, Singh R, Chemtai L, Semeere A, Byakwaga H, Grant M, Laker-Oketta M, Lagat C, Collier S, Maurer T, Martin J, Bassett IV, Butler L, Kiprono S, Busakhala N, Freeman EE. Barriers and facilitators to chemotherapy initiation and adherence for patients with HIV-associated Kaposi’s sarcoma in Kenya: a qualitative study. Infect Agent Cancer 2022; 17:37. [PMID: 35794634 PMCID: PMC9258164 DOI: 10.1186/s13027-022-00444-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022] Open
Abstract
Background Kaposi sarcoma is one of the most prevalent HIV-associated malignancies in sub-Saharan Africa and is often diagnosed at advanced stage of disease. Only 50% of KS patients who qualify for chemotherapy receive it and adherence is sub-optimal. Methods 57 patients > 18 years with newly diagnosed KS within the AMPATH clinic network in Western Kenya were purposively selected to participate in semi-structured interviews stratified by whether they had completed, partially completed, or not completed chemotherapy for advanced stage KS. We based the interview guide and coding framework on the situated Information, Motivation, Behavioral Skills (sIMB) framework, in which the core patient centered IMB constructs are situated into the socioecological context of receiving care. Results Of the 57 participants, the median age was 37 (IQR 32–41) and the majority were male (68%). Notable barriers to chemotherapy initiation and adherence included lack of financial means, difficulty with convenience of appointments such as distance to facility, appointment times, long lines, limited appointments, intrapersonal barriers such as fear or hopelessness, and lack of proper or sufficient information about chemotherapy. Factors that facilitated chemotherapy initiation and adherence included health literacy, motivation to treat symptoms, improvement on chemotherapy, prioritization of self-care, resilience while experiencing side effects, ability to carry out behavioral skills, obtaining national health insurance, and free chemotherapy. Conclusion Our findings about the barriers and facilitators to chemotherapy initiation and adherence for KS in Western Kenya support further work that promotes public health campaigns with reliable cancer and chemotherapy information, improves education about the chemotherapy process and side effects, increases oncology service ability, supports enrollment in national health insurance, and increases incorporation of chronic disease care into existing HIV treatment networks.
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8
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Collier S, Semeere A, Byakwaga H, Laker-Oketta M, Chemtai L, Wagner AD, Bassett IV, Wools-Kaloustian K, Maurer T, Martin J, Kiprono S, Freeman EE. A type III effectiveness-implementation hybrid evaluation of a multicomponent patient navigation strategy for advanced-stage Kaposi's sarcoma: protocol. Implement Sci Commun 2022; 3:50. [PMID: 35562783 PMCID: PMC9102240 DOI: 10.1186/s43058-022-00281-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/07/2022] [Indexed: 11/26/2022] Open
Abstract
Background For people with advanced-stage Kaposi’s sarcoma (KS), a common HIV-associated malignancy in sub-Saharan Africa, mortality is estimated to be 45% within 2 years after KS diagnosis, despite increasingly wide-spread availability of antiretroviral therapy and chemotherapy. For advanced-stage KS, chemotherapy in addition to antiretroviral therapy improves outcomes and saves lives, but currently, only ~50% of people with KS in western Kenya who have an indication for chemotherapy actually receive it. This protocol describes the evaluation of a multicomponent patient navigation strategy that addresses common barriers to service penetration of and fidelity to evidence-based chemotherapy among people with advanced-stage KS in Kenya. Methods This is a hybrid type III effectiveness-implementation study using a non-randomized, pre- post-design nested within a longitudinal cohort. We will compare the delivery of evidence-based chemotherapy for advanced-stage KS during the period before (2016–2020) to the period after (2021–2024), the rollout of a multicomponent patient navigation strategy. The multicomponent patient navigation strategy was developed in a systematic process to address key determinants of service penetration of and fidelity to chemotherapy in western Kenya and includes (1) physical navigation and care coordination, (2) video-based education, (3) travel stipend, (4) health insurance enrollment assistance, (5) health insurance stipend, and (6) peer mentorship. We will compare the pre-navigation period to the post-navigation period to assess the impact of this multicomponent patient navigation strategy on (1) implementation outcomes: service penetration (chemotherapy initiation) and fidelity (chemotherapy completion) and (2) service and client outcomes: timeliness of cancer care, mortality, quality of life, stigma, and social support. We will also describe the implementation process and the determinants of implementation success for the multicomponent patient navigation strategy. Discussion This study addresses an urgent need for effective implementation strategies to improve the initiation and completion of evidence-based chemotherapy in advanced-stage KS. By using a clearly specified, theory-based implementation strategy and validated frameworks, this study will contribute to a more comprehensive understanding of how to improve cancer treatment in advanced-stage KS. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00281-7.
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Affiliation(s)
| | | | | | | | - Linda Chemtai
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Ingrid V Bassett
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Jeffrey Martin
- University of California San Francisco, San Francisco, California, USA
| | - Samson Kiprono
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Moi University, School of Medicine, Department of Internal Medicine, Eldoret, California, USA
| | - Esther E Freeman
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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9
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Ngalamika O, Munsaka S, Lidenge SJ, West JT, Wood C. Antiretroviral Therapy for HIV-Associated Cutaneous Kaposi's Sarcoma: Clinical, HIV-Related, and Sociodemographic Predictors of Outcome. AIDS Res Hum Retroviruses 2021; 37:368-372. [PMID: 33386064 PMCID: PMC8112720 DOI: 10.1089/aid.2020.0099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Kaposi's sarcoma (KS) is an AIDS-defining malignancy that can improve or worsen with antiretroviral therapy (ART). We aimed at identifying clinical, HIV-related, and sociodemographic factors associated with either progression or nonprogression (regression or stable disease) of ART-treated HIV-associated KS in patients with limited cutaneous disease. We conducted a prospective cohort study of ART-treated HIV-associated KS cases. Clinical, HIV-related, and sociodemographic variables were collected at baseline, and patients were followed up to determine treatment outcomes. Cox regression, linear mixed effects model, and Spearman's rank correlation were used for analysis. Half (50%) of the study participants had KS regression or stable disease, whereas the other half (50%) had disease progression during the treatment and follow-up period. Among the data analyzed, presence of KS nodules at baseline (hazard ratio = 5.47; 95% confidence interval = 1.32-22.65; p = .02) was an independent predictor of poor treatment outcome. Progressors and nonprogressors were indistinguishable in the changes they experienced in the HIV plasma viral load and CD4 counts as a result of ART. Even when cutaneous presentation is limited, the presence of nodular morphotype KS lesions should be considered an indicator for combined ART plus chemotherapy. Temporal trends in CD4 counts and HIV viral loads did not correlate with treatment outcome in ART-treated HIV-associated KS.
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Affiliation(s)
- Owen Ngalamika
- Dermatology and Venereology Section, Adult Hospital of the University Teaching Hospitals, University of Zambia School of Medicine, Lusaka, Zambia
| | - Sody Munsaka
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Salum J. Lidenge
- Ocean Road Cancer Institute, Academic and Research Unit, Dar es Salaam, Tanzania
- Muhimbili University of Health and Allied Sciences, Clinical Oncology Department, Dar es Salaam, Tanzania
- Nebraska Center for Virology, Lincoln, Nebraska, USA
- School of Biological Sciences, and University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - John T. West
- Nebraska Center for Virology, Lincoln, Nebraska, USA
- Department of Biochemistry, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Charles Wood
- Nebraska Center for Virology, Lincoln, Nebraska, USA
- School of Biological Sciences, and University of Nebraska-Lincoln, Lincoln, Nebraska, USA
- Department of Biochemistry, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
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10
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Freeman EE, McMahon DE, Laker-Oketta M. Time to address disparities in the standard of care for Kaposi sarcoma. Lancet 2020; 395:1169-1170. [PMID: 32145826 DOI: 10.1016/s0140-6736(20)30473-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/14/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Esther E Freeman
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | - Devon E McMahon
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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