Triple therapy of vincristine, bleomycin and etoposide for children with Kaposi sarcoma: Results of a study in Malawian children.

BACKGROUND: Kaposi sarcoma (KS) is the most common paediatric cancer in human immunodeficiency virus (HIV) endemic countries of sub-Saharan Africa, but there is little research on management and outcomes. METHODS: Children with KS at Queen Elizabeth Central Hospital, Blantyre, Malawi treated between August 2012 and March 2015 with six courses of vincristine, bleomycin and etoposide combination chemotherapy, including antiretroviral therapy (ART) if HIV infected, were studied and outcomes compared with previously reported results. FINDINGS: Fifty-six children were included; 38 (68%) were male; and 48 (86%) were HIV positive, of whom 36 (77%) were on ART at diagnosis. Median age at diagnosis was 8 years (interquartile range [IQR] 3-12) and median follow-up was 16.9 months (IQR 3.4-36.4). Quality of life improved in 45 (80%) children; the median Lansky Score increased from 80% pre-treatment to 100% post-treatment. Eighteen (32%) children had complete response to treatment. At 12 months, overall survival was 71% (95% confidence interval [CI] 56-82) and event-free survival (event = death, loss to follow-up or relapse) was 50% (95% CI 36-63). At 1 year, the risk of loss to follow-up was 13.4%. In a previous, same-site, randomized controlled study of vincristine monotherapy, vincristine and bleomycin, or oral etoposide, oral etoposide monotherapy had the best outcome with survival at 12 month of 66% (95% CI 46-80) and event-free survival of 52% (95% CI 33-68); however, loss to follow-up was not reported. CONCLUSION: Overall survival, event-free survival and quality of life appear to have improved with this three-agent combination chemotherapy; however larger, randomized studies are needed to determine optimal management.

Bedside paediatric HIV testing in Malawi: Impact on testing rates.

Background: Provider initiated testing and counselling (PITC) is recommended for all inpatients in Malawi if they have not been tested in the previous 3 months. However testing rates remain low among children. We audited the effect of implementing a bedside diagnostic HIV testing service to determine if it would improve testing rates amongst paediatric inpatients. Methods: We audited the existing HIV testing service to determine the numbers of children being tested for HIV. This was followed by the introduction of a bedside diagnostic service followed by re-audit. Bedside testing was facilitated by health systems strengthening measures including identification of suitable counsellors, appropriate supervision and remuneration. Results: In the initial audit in March-April 2014, 85 (63%) of 135 children had documented HIV tests.. Following implementation of the bedside HIV testing service, there was a significant increase in the proportion of children whose HIV status was known. On re-audit in July 2015, 110 (94.8%) of 116 children had documented HIV tests (p<0.001). Of those with documented tests, 94.5% had been tested within the last 3-months compared to 61% in 2014. Following the introduction of the service, the proportion of children tested for HIV during admission increased from 31.9% to 68.1% (p<0.001). Conclusions: Implementation of a bedside testing service at Queen Elizabeth Central Hospital significantly increased HIV testing among paediatric inpatients. This has important implications in establishing earlier treatment, reducing HIV-associated morbidity and mortality.