The Emerging Threat of Cancer In Sub-Saharan Africa: Lessons Learned From HIV

Issue 27 Summer/Fall 2016

Entrance to Debre Tabor General Hospital

Over the past decade, the global HIV epidemic has been transformed. The availability of effective HIV treatment for millions of people living with HIV in sub-Saharan Africa has transformed HIV from what was once considered "a death sentence" to a chronic manageable condition.1

By the end of 2015, it is estimated that 15 million people in low and middle income countries have initiated HIV antiretroviral therapy (ART).2

However, as HIV-infected individuals are living longer, due to more effective and better-tolerated medications and service delivery mechanisms, they are now at risk for the development of cancers that typically occur at middle and older ages.

Since first recognized, specific cancers have been associated with HIV infection. Kaposi's sarcoma among young individuals, particularly gay men, was an early and common manifestation of HIV disease. Together with non-Hodgkins lymphoma, both were included as two criteria for an AIDS diagnosis.

With recognition of the importance of HIV infection among women, cervical cancer was added as another criterion for an AIDS diagnosis. This was based on evidence that suggested a more rapid progression of cervical dysplasia (abnormal cell growth) among HIVinfected women and a higher prevalence of cervical cancer.

However, with expansion of effective antiretroviral therapy (ART), the occurrence of these cancers and other AIDS-related infections has decreased substantially. With this decline, data indicate that non-AIDS conditions have gained prominence, so that non-AIDS complications now exceed AIDSdefining complications as causes of morbidity and mortality.3-6

Currently, for example, cancers, liver, heart and kidney diseases are the major threats that such patients face. It is also anticipated that the adoption of new WHO 2015 guidelines will help patients. Those guidelines stress the prompt identification and treatment of all HIV-infected individuals, regardless of disease stage.

These efforts should help more HIVinfected individuals get diagnosed quickly via expanded HIV testing efforts, so they can then access treatment.7

Remarkable changes like these will help HIV-infected patients live longer. But as they do so, it is expected that cancer will become a leading cause of illness for HIV-infected individuals in Africa.

The critical question now, then, is how will countries in sub-Saharan Africa that have been severely impacted by the HIV/AIDS epidemic confront this new health threat? And how will lessons learned from the global HIV response guide their efforts to confront cancer among HIV-infected persons and in the general population?

The current reality is that there are few cancer-related resources in most countries in sub-Saharan Africa. For example, there are only limited surveillance systems to provide even a sense of the magnitude of the cancer burden in these countries.

There is also a severely restricted access to cancer diagnostic methods and treatment - an unlikely match for the current and anticipated demand for such services.

It is estimated that 6 percent of the 14.1 million cancer cases worldwide occur among people living in the African region.8 However, these findings are likely an underestimation, due to limited ability to diagnose cancer and the lack of cancer registries, which are used to keep track of cancer cases in resourcerich countries.

The cancer diagnosis and management services that do exist are largely overwhelmed and situated at a handful of health facilities, often situated in the countries' capital cities. This means that cancer patients in sub Saharan Africa often face enormous difficulty in accessing the few available services, due to the need for distant travel and the unaffordable costs of diagnostic tests, chemotherapy and radiation therapy.

Such patients often face great impediments and suffer from untreated cancer, often dying without access to treatment, pain relief or palliative care.

However, the response to the HIV epidemic in sub-Saharan Africa does offer important lessons to inform the response to cancer across the continent. One critical feature that enabled the success of the HIV response was the adoption of a public health approach. This approach is centered on one important principle-to get high-quality health services to the largest number of individuals in need, whoever and wherever they are.

This strategy is in stark contrast to the more common approach in Africa, which typically offers high quality services to only the fortunate few.

Another important tenet of the public health approach is to focus on use of simple, cost-effective and consistent systems for diagnosis and management. For HIV, the use of such a simple, uniform and low-cost diagnosis methods, generic low-cost medications and consistent laboratory testing schedules has been critical to the ability to reach millions who needed HIV treatment.

Another principal critical to the success of the HIV scaleup was the embrace of 'task shifting' as a means to achieving broad access, due to the lack of a sufficient number of physicians in many African countries. For example, task shifting empowered capable nurses to work as the main providers of care. Research has shown that the quality of the HIV services provided by nurses is similar in quality to that provided by physicians.9

Finally, another guiding principle central to the public health approach is the engagement of affected communities. This has meant involving people living with HIV in every aspect of their care, including their having a voice in the design and implementation of health programs that serve them.

As African countries face the challenge of cancer among their populations, it behooves these countries - as well as the global community - to consider the lessons learned from the response to the HIV epidemic, rather than reinventing the wheel.10

Adopting a public health approach may therefore enable these countries to successfully tackle the challenge of cancer among those now living with HIV, as well as among the rest of their populations.

Ultimately, measurable success in confronting cancer will depend on securing the needed resources, strong political will and - most importantly - a commitment to high quality services to all those who need them. Nothing short of this is acceptable.

Dr. Steven Monroe Lipkin

Wafaa M El-Sadr, MD, MPH, MPA
Director, ICAP at Columbia University Director, Global Health Initiative
University Professor of Epidemiology and Medicine
Mathilde Krim-amfAR Professor of Global Health
Columbia University
New York, NY

Dr. Steven Monroe Lipkin

Katherine Harripersaud, MPH
Project Coordinator ICAP at Columbia University
Columbia University
New York, NY

References

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  2. UNAIDS. UNAIDS: Fact Sheet 2015 - Global Statistics. Available from: http://www.unaids.org/en/resources/campaigns/HowAIDSchangedeverything/factsheet.
  3. Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. The New England journal of medicine. 2015.
  4. Smith CJ, Ryom L, Weber R, Morlat P, Pradier C, Reiss P, et al. Trends in underlying causes of death in people with HIV from 1999 to 2011 (D: A: D): a multicohort collaboration. The Lancet. 2014;384(9939):241-8.
  5. Engels EA, Biggar RJ, Hall HI, Cross H, Crutchfield A, Finch JL, et al. Cancer risk in people infected with human immunodeficiency virus in the United States. International journal of cancer. 2008;123(1):187-94.
  6. Shiels MS, Pfeiffer RM, Engels EA. Age at cancer diagnosis among persons with AIDS in the United States. Annals of internal medicine. 2010;153(7):452-60.
  7. WHO Guidelines Approved by the Guidelines Review Committee. Guideline on When to Start Antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV. Geneva: World Health Organization, Copyright (c) World Health Organization 2015.; 2015.
  8. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. International journal of cancer. 2015;136(5):E359-86.
  9. Emdin CA, Chong NJ, Millson PE. Non-physician clinician provided HIV treatment results in equivalent outcomes as physician-provided care: a meta-analysis. J Int AIDS Soc. 2013;16:18445.
  10. Rabkin M, El-Sadr WM. Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases. Global public health. 2011;6(3):247-56.