Today, people living with HIV/Aids live longer due to effective antiretroviral treatment but cancer and other non-communicable diseases are contributing to a growing proportion of deaths of those in this category.
HIV/Aids and cancer care and treatment are provided free of charge by the government. However, HIV/Aids is associated with higher mortality for all cancer patients. This is because it suppresses the body’s immunity to fight diseases, including cancer cells.
Dr Noleb Mugisha, an oncologist at the Uganda Cancer Institute (UCI), says: “There are abnormal cells that develop in our bodies but the immune system is able to suppress them to reduce the cancer. When a body is infected with HIV, its immunity is suppressed, which allows any cancerous cells to easily thrive and multiply in the body.”
The high mortality rate in cancer patients with HIV, for instance, is linked to lower CD4 and haemoglobin levels. As a result, the cancer cells multiply very fast until a stage where the body’s immunity cannot slow them down.
Dr Mugisha also notes that there could be a synergy between human papillomavirus (HPV) and HIV virus, which easily make cancerous cells in the body as they multiply. He says the body has a surveillance mechanism, which is depressed by the HIV, thereby increasing one’s risk of developing cancer.
The risk of getting HPV virus, which causes cervical cancer, increases with HIV because the virus is known to weaken the immune system. “A weakened immune system that has been affected by HIV fosters faster progression of HPV to multiply in the body, which makes an HIV patient prone to cervical cancer,” Dr Mugisha says.
He adds that there is a high prevalence of late stage cervical cancer among women living with HIV even when they are on antiretroviral treatment (ART) and regular care in clinics where practitioners understand the risk for cervical cancer.
Dr Mugisha says girls, who engage in sexual intercourse below 17 years and those with more than three sexual partners, are more likely to present with late stage cervical cancer.
As a result, he says HIV care guidelines in Uganda should be updated to include cervical cancer screening in the age group. “Traditionally, diseases such as HIV that have specialised care clinics usually pay more attention to that particular disease and the guidelines for their assessment only focus on TB and neglect other diseases. These are problems that are likely to appear as a result of HIV,” says Dr Mugisha.
He says there is no screening for cancer in HIV/Aids clinics because the guidelines and funding only focus on TB and not cervical cancer.
“There is no space and equipment in the HIV clinic where screening of the women would be done and the personnel working in the clinic are not trained to do the screening,” Dr Mugisha says.
He advises that cervical cancer screening should be done every three years for HIV-negative women and annually for those living with the disease.
“HIV positive women are five times more likely to catch cervical cancer than their negative counterparts and the time they come at UCI, their cancer has advanced to stage three or even four. Not all HIV patients are tested for cancer for several reasons,” he says.
However, Dr Mugisha says government lacks the infrastructure and trained personnel to carry out the screening. This is one of the missed opportunities that have contributed to high cervical cancer death rates.
“For whatever complaint a woman may have that is not related to HIV and TB, they are usually referred to another section. Some women feel discouraged so they do not go for screening in another section because it requires another day yet some come from far places,” he says
Dr Mugisha says by the time such a woman goes for screening, it is usually too late and the cancer has advanced to a stage that it cannot be reversed.
“There is, therefore, need to integrate routine screening with HIV care,” he says.
Dr Mugisha says poor health-seeking behaviour among the population has contributed to increased mortality of cancer patients with HIV.
“Most people will only go to hospital when there is pain or a physical symptom yet this is the time when the cancer is in the advanced stage and very difficult to treat. If people can learn to go for routine screening, it would be easy for them to prevent such cancers that are HIV related,” he says.
Dr Mugisha says there is underutilisation of comprehensive community cancer programme at UCI, which offers free screening.
Dr James Kafeero, a medical officer at UCI, says the cancers that are HIV-related are infection related.
About 50 per cent of the cervical cancer patients, according to Dr Mugisha, are living with HIV. He says any intimate skin contact with a person that has the HPV virus can lead to transmission of the disease.
“It is not only transmitted through sexual intercourse and anyone can catch the virus even when they are HIV negative,” Dr Mugisha says.
However, he says when a person is negative, their immune system is strong and the white blood cells are able to fight the virus from producing cancerous cells even with persistent infections.
The risk of getting the HPV virus, which causes cervical cancer, increases with HIV because the virus is known to weaken the immune system. “A weakened immune system that has been affected by HIV fosters faster progression of HPV to multiply in the body, which makes an HIV patient prone to cervical cancer,” he says.
Dr Mugisha says symptoms of cervical cancer include intermenstrual and spontaneous bleeding, a foul discharge, pain during sex, rectal- vaginal fistula and yellowing of eyes.
Dr Kafeero says Kaposi sarcoma mainly affects mid age groups at an incidence of 266 per 100,000. “This type of HIV-related cancer manifests more on the skin but it can also begin in the blood vessels, lungs and intestines. It occurs as dark lesions on the skin and 90 per cent of the patients are HIV positive. It causes bleeding in the lungs and gastro intestinal bleeding so one of the commonest symptoms is bloody cough and stool depending on where it is,” he says.
The doctors say this cancer starts in the lymphatic system, which is connected to the blood stream. They say the person develops fever, loss of appetite, swelling in the groins, neck and the lymph nodes, as is the case with TB. There can also be accumulation of water behind the lungs. This is rare but it happens.
Primary CNS lymphoma
This type of cancer presents very late for people who have lived with HIV for a long time. Dr Mugisha says the cancer signals a severely suppressed immune system due to HIV. “The person becomes lethargic, develops focal neurological signs such as convulsing on one side of the body. There is always a change in the mental state of the person and they will look confused and not oriented,” he says.
Other cancers associated with HIV/Aids include anal, vaginal and penile.
October free testing/ discounts
International Hospital Kampala: Prostate cancer at 30 per cent discount, HPV-V brush at Shs125,000, PAP smear (Cervical Cancer) 30 per cent, breast cancer physical examinations.
Alexander Medical Center: Free doctor’s consultation and breast cancer screening, 50 per cent discount on cervical cancer screening for two weeks.
UMC Victoria hospitals. Free breast cancer screening, free consultation, 50 per cent discount on extra investigation such as breast ultra-sound @ Shs30,000 and cervical cancer screening at @ Shs50,000.