Background:  Kaposi sarcoma (KS) is the most common HIV-related malignancy and is associated with a 4-fold increase in mortality of patients on ART in Khayelitsha, South Africa. Little is known about the evolution of KS on ART in resource-poor settings.  

Methods:  We conducted a retrospective study of patients with KS enrolled on ART in a primary care setting between May 2001 and January 2007. Site of lesion, grading, treatment, and outcomes on ART are described. Kaplan-Meier methods and Cox proportional hazards analysis were used to model survival and determinants of mortality and disease progression.

Results:  Of 6292 adults enrolled on ART during the study period, 214 (3.4%) had KS. A folder review was done for the majority of these patients (n = 188; 88%). Median age was 33 and the majority (60%) was female. The most common site of lesions were oral (65%) and the lower extremities (56%); 124 (69%) had T1 disease and 101 (54%) were treated with ART alone. Of the 86 patients referred for further treatment, 55 (64%) received chemotherapy, 44 (51%) received radiotherapy, and 2 (2%) underwent surgery; 7 (4%) had symptoms of KS immune reconstitution syndrome. KS outcome data were available for 94 patients (50%). Of these, 18 (19%) had complete remission of lesions, 43 (46%) had partial improvement, 8 (8%) had no change in lesions, and 25 (26%) had progressive disease. Of the total, 66 (35%) patients died, 47 (25%) were lost to follow-up, 9 (5%) were transferred out, and 62 (33%) were alive and in care. In multivariate analysis, stage T1 and S1 disease were associated with mortality (OR respectively 2.93, p = 0.006 and 10.4, p = 0.002). Determinants of disease progression in multivariate analysis included absence of referral to oncology clinic (OR 19.9, p <0.001), T1 disease (OR 22.2, p = 0.004) and S1 disease (OR 12.1, p = 0.03).

Conclusions:  The prevalence of KS among patients starting ART in Khayelitsha was low. However, despite the advent of ART and other treatments for KS, mortality remains very high (60% if losses to follow-up are counted as dead). The major risk factors for mortality were advanced (T1 or S1) disease and failure to augment ART with additional KS-specific therapy. Improved studies on the effectiveness of accessible chemotherapy regimens and related side-effects in resource-limited settings are needed. Efforts to improve retention in care for patients with KS are also needed.