Those with KS had failed to suppress HIV viral load to ,400 copies/mL while just under 8 of those without KS had failed to achieve suppression. Among those who survived to a year on treatment, similar proportions failing to achieve virologic responses were noted (7 vs. 10 ). The relative risk for failure to achieve virologic suppression suggests that KS patients fared better at 6 (RR: 0.82; 95 CI: 0.38?.79) and 12 months (RR: 0.25; 95 CI: 0.06?.00) after initiation of ART compared to those without KS though these estimates lacked precision. Results from sensitivity13.8.8.5.18745 809 (7.4 ) 1.0 1.0 18745 335 (3.1 ) No KS 1.4.Lost to follow up1794 (14.0 )43 (18.3 )26 (11.1 )3.62 (2.71?.84)985 (7.7 )LTFU**4.05 (2.95?.55)Adjusted HR (95 CI)`1.Crude HR (95 CI) {3.22 (2.51?.15)1.3.63 (2.76?.77)1.Person time Rate/100 (years) pys*13.1.28.3.7.1248 (9.7 )913 (7.1 )64 (27.2 )54 (23.0 )Within first year of ARTAfter first year of ARTOver total follow-upDeathNo KSNo KSKSKSKS10 (6.5 )Deaths4.2.03 (1.08?.80)2.30 (1.08?.89)17 (11.0 )7.{Kaposi Sarcoma and ART in HIV-Positive PopulationFigure 1. Cumulative incidence of mortality after ART initiation by KS status. doi:10.1371/journal.pone.0064392.ganalyses again did not qualitatively change the results at either 6 or 12 months on treatment.DiscussionAIDS-related malignancies are increasing in significance as the HIV epidemic matures, particularly in resource-limited settings. These settings bear the greatest burden of disease due to cancers yet are most limited in terms of drug options, infrastructure and staffing required to effectively treat these conditions. As access to ART continues to scale-up and models of HIV care shift away from specialist services to decentralised clinics, investigating factors that impact on the effective response to ART is important. ART has shown much promise in the Eliglustat treatment of early stage KS [10?16,24] but the effect of KS on response to ART is not clear. We found the prevalence of Kaposi sarcoma among this HIV?infected treatment naive population was 1.8 , very similar to the prevalence of 1.6 seen in Nigeria [25], and somewhat lower than seen among European cohorts (3.8?.4 ) in the late 1990s [26?28]. While there may be country-level differences in prevalence of KS, our figures could underestimate the true prevalence in this setting for several reasons. Firstly, diagnosis of KS in HIV outpatient clinics may be impaired by limited access to oncology and POR8 web histopathology services, as well as lack of training on early recognition KS by primary care staff. A recent study in South Africa noted that 46 of study subjects were diagnosed with KS and HIV at the same time [29] and earlier studies have shown high pre-ART attrition underestimates KS prevalence; in South Africa the prevalence of KS including pre-ART subjects was estimated at 3.4 [8]. Additionally, limited communication and linkage between oncology and outpatient services hampers the recording of cancer diagnoses in HIV clinic patient records and use of national cancer registry databases to ascertain cancer diagnoses is not routine. We demonstrated a substantially increased risk of mortality associated with KS. The risk of death was four times greater among the KS group in the first year on ART and though the riskdecreased thereafter, those with KS were still twice as likely to die after the first year of treatment as those without KS after adjustment for measured confounders. This is in keeping with previous findi.Those with KS had failed to suppress HIV viral load to ,400 copies/mL while just under 8 of those without KS had failed to achieve suppression. Among those who survived to a year on treatment, similar proportions failing to achieve virologic responses were noted (7 vs. 10 ). The relative risk for failure to achieve virologic suppression suggests that KS patients fared better at 6 (RR: 0.82; 95 CI: 0.38?.79) and 12 months (RR: 0.25; 95 CI: 0.06?.00) after initiation of ART compared to those without KS though these estimates lacked precision. Results from sensitivity13.8.8.5.18745 809 (7.4 ) 1.0 1.0 18745 335 (3.1 ) No KS 1.4.Lost to follow up1794 (14.0 )43 (18.3 )26 (11.1 )3.62 (2.71?.84)985 (7.7 )LTFU**4.05 (2.95?.55)Adjusted HR (95 CI)`1.Crude HR (95 CI) {3.22 (2.51?.15)1.3.63 (2.76?.77)1.Person time Rate/100 (years) pys*13.1.28.3.7.1248 (9.7 )913 (7.1 )64 (27.2 )54 (23.0 )Within first year of ARTAfter first year of ARTOver total follow-upDeathNo KSNo KSKSKSKS10 (6.5 )Deaths4.2.03 (1.08?.80)2.30 (1.08?.89)17 (11.0 )7.{Kaposi Sarcoma and ART in HIV-Positive PopulationFigure 1. Cumulative incidence of mortality after ART initiation by KS status. doi:10.1371/journal.pone.0064392.ganalyses again did not qualitatively change the results at either 6 or 12 months on treatment.DiscussionAIDS-related malignancies are increasing in significance as the HIV epidemic matures, particularly in resource-limited settings. These settings bear the greatest burden of disease due to cancers yet are most limited in terms of drug options, infrastructure and staffing required to effectively treat these conditions. As access to ART continues to scale-up and models of HIV care shift away from specialist services to decentralised clinics, investigating factors that impact on the effective response to ART is important. ART has shown much promise in the treatment of early stage KS [10?16,24] but the effect of KS on response to ART is not clear. We found the prevalence of Kaposi sarcoma among this HIV?infected treatment naive population was 1.8 , very similar to the prevalence of 1.6 seen in Nigeria [25], and somewhat lower than seen among European cohorts (3.8?.4 ) in the late 1990s [26?28]. While there may be country-level differences in prevalence of KS, our figures could underestimate the true prevalence in this setting for several reasons. Firstly, diagnosis of KS in HIV outpatient clinics may be impaired by limited access to oncology and histopathology services, as well as lack of training on early recognition KS by primary care staff. A recent study in South Africa noted that 46 of study subjects were diagnosed with KS and HIV at the same time [29] and earlier studies have shown high pre-ART attrition underestimates KS prevalence; in South Africa the prevalence of KS including pre-ART subjects was estimated at 3.4 [8]. Additionally, limited communication and linkage between oncology and outpatient services hampers the recording of cancer diagnoses in HIV clinic patient records and use of national cancer registry databases to ascertain cancer diagnoses is not routine. We demonstrated a substantially increased risk of mortality associated with KS. The risk of death was four times greater among the KS group in the first year on ART and though the riskdecreased thereafter, those with KS were still twice as likely to die after the first year of treatment as those without KS after adjustment for measured confounders. This is in keeping with previous findi.
