HIV Positive Adults and Kaposi Sarcoma Cases Prevalence in Namibia

HIV/AIDS is a global pandemic. The annual number of new HIV infections has steadily declined and due to the significant increase in people receiving antiretroviral therapy, the number of AIDS-related deaths has also declined. Namibia is one of the worst affected countries by HIV/AIDS in the world. Kaposi sarcoma is an opportunistic malignancy that occurs in HIV positive patients, the epidemic of AIDS-related type. Even though Kaposi sarcoma incidence has declined during the late 1990s with the advent of highly active antiretroviral therapy (HAART) against HIV, Namibia must invest more in the screening and treatment of this condition. This is a quantitative study that enumerated the number of KS cases found within a HIV/AIDS population in Namibia. It was a case series that quantified retrospectively, the number of cases of Kaposi sarcoma recorded over a period of 1 year at the Windhoek Central Oncology Clinic using convenience sampling method. The data collected was recorded and entered an Epi-info 7 document project for data analysis. Data was used to calculate the prevalence and relevant frequencies. During the study, 93 cases of KS were reviewed. Prevalence of KS is HIV positive adults in Namibia was 0.03%. The frequency in males (63.44%) was more than female counterparts (36.56%). The ages of patients ranged between 21 and 75 years. The mean age was 41.5 years. Similarly, the mode and median age distribution of KS in HIV positive adults in Namibia was 41 years. The frequency of KS was highest in the age group of 38-47 years of age. Histologically diagnosis (81.72%) predominated over clinical diagnosis (18.28%). The highest frequency of KS lesion location was found in the legs, specifically left leg, and right leg, 15.05% and 13.98% respectively. Overall, the prevalence of KS in HIV positive adults in Namibia is relatively low according to ratios but 93 cases were reported over a period of one year which is a significant number independently.


Introduction and Background
Human immunodeficiency virus (HIV) is an incurable and very potent virus that lowers the immunity and allows for a variety of diseases to flourish in the body. This state of severe immunosuppression and attack by the opportunistic infections is a stage of the viral infection known as AIDS (acquired immunodeficiency syndrome) [1][2][3].
HIV/AIDS has been in existence for at least two decades now since its initial description in the 1980s. The overall growth of the epidemic has stabilized in recent years [4,5]. The annual number of new HIV infections has steadily declined and due to the significant KSHV is now thought to be largely transmitted by saliva. Although associated with sexual risk factors, these may just be a surrogate for close contact. Heterosexual risk factors largely do not play a role here. Transmission by blood or blood products can occur but use of leukopoor stored blood is likely to significantly reduce this risk.
Transmission of KSHV may occur during solid organ donation, but it does not appear to affect clinical outcome in terms of survival or graft loss [12]. There may be an increase of incidence of KS in patients in solid organ recipients that are seropositive versus those that seronegative (Medscape, 2014).

Problem Statement and Study Justification
Before the AIDS pandemic, KS rarely occurred, however, there had been a rise in the incidence of this type of cancer with rise of the HIV/AIDS pandemic in the 1990s. But with new treatment for AIDS, KS has become less common in the United States, with about 6 cases per million people each year. Regardless, HHV8 is still commonly found in HIV infected people than in the general population. It is estimated that an HIV-infected person has 20,000 times increased risk of developing KS compared with people without HIV (American cancer association, 2010) [13,14]. There are no publications on this topic in Namibia therefore this study would be significant step in acquisition more knowledge about the disease than is already known in this country. This study may also trigger a more extensive research on the subject apart from creating awareness to the MoHSS.

Methodology
This is a quantitative study that enumerated the number of KS cases found within a HIV/AIDS population in Namibia.

Study Population
The study was carried out at Windhoek central hospital.
Windhoek Central Hospital and Katutura Hospital together called the Windhoek State Hospital Complex (WSHC) form the national referral hospital. The WSHC has a capacity of 1383 beds. This is the last point in the referral system. Services which are rendered and departments by the national referral hospitals are as follows: Specialists such as pediatricians, physicians, obstetricians and gynecologists, general surgeons and oncologists; services of cardiothoracic surgeons, neurosurgeons and plastic surgeons should be provided on a visiting basis. In addition, intensive care, operating theatres, medical laboratory services, radiological services, nuclear medicine, pharmaceutical services, and rehabilitation services are all departments and facilities available.
The oncology clinic, formally known as the Chris Bernard oncology clinic, is the main oncology clinic in Namibia and it receives cancer patient referrals from all the regions. It receives or treats approximately 3000 cancer patients (2012). The center is rich with information on all types of cancers found in Namibia. All the Kaposi sarcoma cases are sent here for treatment [15][16][17]. The Kaposi sarcoma patients have files allocated to them and as they enter the center, they are recorded in registries that are specific for a type of cancer as all the other types of cancers. The data was collected from the 1st of August to 12th of September 2014.

Sample Size Determination
Sampling was done according to the number of HIV positive patients who developed Kaposi sarcoma and received treatment at the Windhoek oncology clinic. The sampling method that was employed in this study was convenience sampling, meaning every individual that had presented/referred to the oncology clinic with Kaposi sarcoma between June 2013 and June 2014, which was the study period. The sample size estimation will entirely depend on the number of subjects that presented with the cancer.

Study Design
A case series study was employed in this study which is a descriptive study. A case series (also known as a clinical series) is a medical research descriptive study that tracks patients with a known exposure given similar treatment or examines their medical records for exposure and outcome. It can be retrospective or prospective and usually involves a smaller number of patients.
Case series may be consecutive or non-consecutive, depending on whether all cases presenting to the reporting authors over a period were included, or only a selection.
The cases series retrospective study used existing data that has been recorded for reasons other than this research. This study looked backward in time using medical records of patients who are already known to have Kaposi sarcoma during the study period.
Existing medical records/patient files in the oncology clinic were reviewed for Kaposi sarcoma cases using the data collection tool i.e., data collection sheet, from 1st June 2013 to 1st June 2014, thus a period of 1 year of the most recent data recorded.

Data Collection
Data was collected from an oncology center, meaning that data was collected from a population of cancer patients. The population of focus was all the Kaposi sarcoma cases. The main objective of the study was to determine the prevalence of Kaposi sarcoma in HIV positive adults in Namibia; therefore, the focus was further

Study Limitations
This study was not without its limitations. The study was initially planned to be carried out in the northern part of Namibia which is one of the main regions affected by HIV/AIDS but I was told that all the records regarding Kaposi sarcoma was in Windhoek as all their Kaposi sarcoma patients were referred there for treatment.
Therefore, the study could no longer be carried out at the CDC clinic in Oshakati intermediate hospital because better records were guaranteed at the Windhoek central hospital oncology clinic. This also led to the change in the study area. Initially, the area of focus was specifically Oshakati hospital, but the oncology clinic had records of patients with Kaposi sarcoma from all over the country.

Prevalence of Kaposi Sarcoma in HIV Positive Adults in Namibia
The availability and free access of HAART, the prevalence is Namibia is low, 0.03% [19]. This means that the distribution of ARV's is almost efficient and that the patients are adherent to their medication, preventing them from going into the 4th stage of the disease. This could also be attributed to the fact that; KS is not as infectious as the highly infectious Tuberculosis and therefore not as prevalent [20].

Gender Frequencies
According to the Table 1, from the total number of 93 cases reviewed in this study, 34 cases were females (36.56%), and 59 cases were males (63.44%). This means that KS was more common in adult HIV positive males (Table 1). This could possibly imply that women in Namibia are less at risk of getting KS because they are more likely to be on treatment and have better adherence than men (Figure 1).

Am J Biomed Sci & Res
Copy@ RSheehama J

Age Frequency
According to followed by the younger age range of 28-37 years with a frequency of 31 (33.33%). The third highest age range with a frequency of 11 (11.83%) was an older age range of 48-57 years ( Table 2). With no other former data to compare with, the frequency of KS in Namibia also decreased in younger patients [22].
The reason could be because the age range of 30-50 may have the highest prevalence of HIV in Namibia therefore is at risk of getting KS ( Figure 2 & Table 3).

Diagnosis Frequency
Kaposi sarcoma is often found when a person goes to the doctor because of signs or symptoms they are having. Sometimes KS may be found during a routine physical exam. If KS is suspected, further  Most of the lesions, as illustrated by the Table 4, are found on the skin. It can either be one of two possibilities, its either cutaneous manifestation of KS is the most common in Namibia or that interior manifestations are poorly diagnosed: low index of suspicion of the doctors.    Most of the lesions are cutaneous manifestations according to Table 4 and as mentioned before, the reason could be that Namibians are mostly prone to cutaneous KS or the is poor diagnosis of KS elsewhere in the body. Unfortunately, studies related to this could not be found for comparison.

Conclusions and Recommendations
Namibia is one of the worst affected countries by HIV/AIDS in One of the opportunistic diseases that attack the body due to immune suppression is a form of cancer known as Kaposi Sarcoma.
Kaposi sarcoma cases have increased with the HIV/AIDS pandemic.
But Kaposi's sarcoma has declined in the era of highly active antiretroviral therapy and the cancer has improved [8].
This study aimed at determining the prevalence of Kaposi Locations of KS lesions found include lesions all over the body, feet, legs, arms, thigh, hard palate, elbow, lumbar area, lungs, nose, penis, big toe, groin, parotid, tongue, tonsils, trunk, and vulva. The highest frequency was found in the legs, specifically left leg, and right leg, 15.05% and 13.98% respectively.