| dc.description.abstract | Non-Hodgkin's lymphoma (NHL) remains the second most common malignant complication in patients with human im-munodeficiency virus (HIV) infection. As we enter the third decade of the acquired immonodeficiency syndrome (AIDS) epidemic, it is apparent tbat the evolution of antiretroviral therapy and the emergence of combination antiviral strate¬gies have greatly affected the natural history of HIV infec¬tion and its neoplastic complications. For example, there may be a trend for declining incidence of AIDS-related lym¬phoma in the United States for the first time. However, in regions of the world where the burden of mv infection is greatest. such as in East Africa. AIDS-related lymphoma is an increasing cause of morbidity and mortality. Treatment of lymphoma has evolved coincident with improvements in antiretroviral therapy. Infusional chemotherapy regimens may offer advantages over other regimens and schedules, but comparative trials have not been done. Clinical trial data are available on which to develop therapeutic strategies to treat this disease in East Africa where pragmatic approaches are needed. Both the differences in manifestations of HIV infection and the inherent difficulties in administering cyto¬toxic chemotherapy in this part of the world must be taken into consideration in planning therapeutic strategies. Im¬proved understanding of the pathogenesis of HIV infection and lymphoma will Likely yield improved therapeutic inter¬ventions as well. [J Natl Cancer Inst 2002;94:718-32]
The World Health Organization estimated that a total of 36.1 million adults and children were living with human immunode-ficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) worldwide in 2000, over 95% of whom lived in developing countries, 25.3 million (70%) in sub-Saharan Af¬rica (l). Nearly 17% of world case subjects (4.2 million) reside in East Africa, in Uganda, Kenya, and Tanzania. It goes without
aying that the AIDS pandemic is evolving in different ways across the globe. Table I provides a demographic snapshot of the AIDS epidemic in the United States and East Africa at the beginning of 2000.
In 1990, investigators from Zaire framed seven obstacles to the optimal management of HfV infection! AIDS in Africa, which still exist today (2). Although an overview of each of these obstacles is beyond the scope of this review, a brief men¬tion of the economic realities of the epidemic and discussion of some of the clinical management issues are needed. The "envi¬ronment of extreme scarcity" (2) with which national AIDS control programs in Africa must confront the epidemic is the most important obstacle that must be overcome and reflects the
greatest difference between the developed and developing world. The enormous human tragedy and economic burden of the AIDS epidemic is staggeri ng (J, <+). The Ii fe expectancy in the nine countries hardest hit by AIDS in Africa is projected to decrease by 16 years between 20 to and 2015 (5). It is estimated that the annual cost of prevention and treatment programs world¬wide alone is $14 billion (6). As we move into the third decade of the pandemic, awareness of the global problem is surfacing in the United States (7-12). There is a great deal of discussion in the press, and in political and scientific communities in most of Africa as well, regarding how newer HIV treatments can be made more affordable and accessible for African patients. As world opinion regarding the feasibility of providing AIDS care in Africa is changing, it is ethically imperative to begin to devise clinical strategies that are pragmatic and suitable for implemen¬tation in this pan of the world to address both HlV infection and its related opportunistic illnesses. We present here an overview of AIDS-related lymphoma and the challenge of treating this tumor that is confronting clinicians in East Africa. These clinical issues are applicable to the management of other neoplasms as well. We contend that it is both reasonable and necessary to design therapeutic trials for the treatment of AIDS-related lym¬phoma, i.e., non-Hodgkins lymphoma (NHL), in this part of the world where the burden of Hl V disease is greatest.
The highly active antiretroviral therapy (HAART) era dates back to 1996 with the general availability of the protease inhibi¬tors. It is now possible, with the emergence of HAART, to achieve more sustained elevations in CD4 lymphocyte counts and effective suppression of HIV replication. Partial immune | en |
