Rapid progression to death after hepatocellular carcinoma diagnosis particularly among persons with advanced HIV disease in Kampala, Uganda

Abstract

AbstractBackgroundHIV infection is associated with more rapid progression of some comorbidities. This study assessed the impact of HIV-infection where the presentation and outcome of HCC was different in persons living with HIV (PLWH) compared to those without HIV infection.MethodsHCC patients attending the Mulago National Referral Hospital in Uganda were enrolled into a natural history study of HCC between March 2015 and February 2019. Standardized methods were used to collect clinical, ultrasound and laboratory data at enrolment. HCC cases were confirmed based on a combination of clinical, ultrasound, tumor marker and pathology data. Follow-up contact was made at one, three, six, and twelve months post-enrolment to determine vital status. Symptoms and signs at diagnosis and subsequent survival were compared by HIV status. Kaplan Meier curves were used to assess HCC survival.ResultsOf 441 persons with HCC, 383 (87.0%) died within 12 months following HCC diagnosis. The median (IQR) survival was 42 (20, 106) days. The most commonly reported symptom clusters were pain (80%), gastrointestinal symptoms (28%) and anorexia / cachexia (10%), and no differences were detected in these presenting symptoms (nor most other initial findings) in the 79 (18%) PLWH compared to those without HIV. After adjusting for baseline demographic and clinical characteristics, HIV infection was associated with increased mortality but only among those with severe HIV-associated immunosuppression (CD4 count <200 cells per cubic milliliter), aHR (95% C) = 2.12 (1.23-3.53), p=0.004, and not among PLWH with ≥200 CD4 cells per cubic milliliter, aHR (95% C) = 1.15 (0.82-1.60), p=0.417.ConclusionAmong relatively young Ugandans, HCC is a devastating disease with rapid mortality that is especially rapid among PLWH. HIV was associated with slightly higher mortality, notably among PLWH with lower CD4 cell counts. As a substantial majority of PLWH diagnosed with HCC were engaged in HIV care, further investigation should determine the effectiveness of incorporating screening and early identification of HCC among high-risk individuals into existing HIV care programs. Concurrent with growing access to curative localized treatment for HCC in sub-Saharan Africa, leveraging HIV care infrastructure affords opportunities for earlier HCC intervention.