Evaluation of a training intervention to improve cancer care in Zimbabwe: Strategies to Improve Kaposi Sarcoma Outcomes (SIKO), a prospective community-based stepped-wedge cluster randomized trial
Katherine R Sabourin, Margaret Borok, Samantha Mawhinney, Maxwell Matimba, Francis Jaji, Suzanne Fiorillo, Dickson D Chifamba, Claudios Muserere, Busisiwe Mashiri, Chenjerai Bhodheni, Patricia Gambiza, Rachael Mandidewa, Mercia Mutimuri, Ivy Gudza, Matthew Mulvahill, Camille M Moore, Jean S Kutner, Eric A F Simões, Thomas B Campbell, Katherine R Sabourin, Margaret Borok, Samantha Mawhinney, Maxwell Matimba, Francis Jaji, Suzanne Fiorillo, Dickson D Chifamba, Claudios Muserere, Busisiwe Mashiri, Chenjerai Bhodheni, Patricia Gambiza, Rachael Mandidewa, Mercia Mutimuri, Ivy Gudza, Matthew Mulvahill, Camille M Moore, Jean S Kutner, Eric A F Simões, Thomas B Campbell
Abstract
Introduction: Most Zimbabweans access medical care through tiered health systems. In 2013, HIV care was decentralized to primary care clinics; while oncology care remained centralized. Most persons in Zimbabwe with Kaposi sarcoma (KS) are diagnosed late in their disease, and the prognosis is poor. Little is known about whether educational interventions could improve KS outcomes in these settings.
Methods: Interventions to improve KS detection and management were evaluated at eight Zimbabwe primary care sites (four rural/four urban) that provided HIV care. Interventions included a standardized KS clinical evaluation tool, palliative care integration, standardized treatment and improved consultative services. Interventions were implemented between February 2013 and January 2016 using a randomized stepped-wedge cluster design. Sites were monitored for KS diagnosis rates and KS outcomes, including early diagnosis (T0 vs. T1 tumour stage), participant retention and mortality. Analyses controlled for within-clinic correlations.
Results: A total of 1102 persons with suspected KS (96% HIV positive) were enrolled: 47% incident (new diagnosis), 20% prevalent (previous diagnosis) and 33% determined as not KS. Early (T0) diagnosis increased post-intervention, though not significant statistically (adjusted odds ratio [aOR] = 1.48 [95% confidence interval (95% CI): 0.66-3.79], p = 0.37). New KS diagnosis rates increased 103% (95% CI: 11-273%), p = 0.02) post-intervention; although paired with an increased odds of incorrectly diagnosing KS (aOR = 2.08 [95% CI: 0.33-3.24], p = 0.001). Post-intervention, non-significant decreases in 90-day return rates (adjusted hazard ratio [aHR] = 0.69 [95% CI: 0.38-1.45], p = 0.21) and survival (aHR = 1.36 [95% CI: 0.85-2.20], p = 0.20) were estimated.
Conclusions: KS training interventions at urban and rural Zimbabwe decentralized primary care clinics significantly increased overall and incorrect KS diagnosis rates, but not early KS diagnosis rates, 90-day return rates or survival.
Trial registration: ClinicalTrials.gov NCT01764360.
Keywords: HIV; KS; Kaposi sarcoma; palliative care; primary community care; training intervention tools.
Conflict of interest statement
No competing interests were reported by any authors.
© 2022 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.
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References
- Chokunonga E, Borok MZ, Chingonzoh T, Chirenje ZM, Makunike‐Mutsa R, Manangazira P, et al. Pattern of cancer in Zimbabwe in 2016. Zimbabwe National Cancer Registry (ZNCR); 2018.
- Nelson BC, Borok MZ, Mhlanga TO, Makadzange AT, Campbell TB. AIDS‐associated Kaposi sarcoma: outcomes after initiation of antiretroviral therapy at a university‐affiliated hospital in urban Zimbabwe. Int J Infect Dis. 2013;17:e902–6.
- Kingham TP, Alatise OI, Vanderpuye V, Casper C, Abantanga FA, Kamara TB, et al. Treatment of cancer in sub‐Saharan Africa. Lancet Oncol. 2013;14:e158‐67.
- Singogo E, Keegan TJ, Diggle PJ, van Lettow M, Matengeni A, van Oosterhout JJ, et al. Differences in survival among adults with HIV‐associated Kaposi's sarcoma during routine HIV treatment initiation in Zomba district, Malawi: a retrospective cohort analysis. Int Health. 2017;9:281‐7.
- Borok M, Fiorillo S, Gudza I, Putnam B, Ndemera B, White IE, et al. Evaluation of plasma human herpesvirus 8 DNA as a marker of clinical outcomes during antiretroviral therapy for AIDS‐related Kaposi sarcoma in Zimbabwe. Clin Infect Dis. 2010;51:342‐9.
- Bekolo CE, Soumah MM, Tiemtore OW, Diallo A, Yuma JD, Di Stefano L, et al. Assessing the outcomes of HIV‐infected persons receiving treatment for Kaposi sarcoma in Conakry‐Guinea. BMC Cancer. 2017;17:806.
- Sengayi MM, Kielkowski D, Egger M, Dreosti L, Bohlius J. Survival of patients with Kaposi's sarcoma in the South African antiretroviral treatment era: a retrospective cohort study. S Afr Med J. 2017;107:871‐6.
- Chu K, Misinde D, Massaquoi M, Pasulani O, Mwagomba B, Ford N, et al. Risk factors for mortality in AIDS‐associated Kaposi sarcoma in a primary care antiretroviral treatment program in Malawi. Int Health. 2010;2:99‐102.
- Chu KM, Mahlangeni G, Swannet S, Ford NP, Boulle A, Van Cutsem G. AIDS‐associated Kaposi's sarcoma is linked to advanced disease and high mortality in a primary care HIV programme in South Africa. J Int AIDS Soc. 2010;13:23.
- World Health Organization . Summary country profile for HIV/AIDS treatment scale‐up ‐ Zimbabwe. World Health Organization. 2005.
- Challinor JM, Galassi AL, Al‐Ruzzieh MA, Bigirimana JB, Buswell L, So WKW, et al. Nursing's potential to address the growing cancer burden in low‐ and middle‐income countries. J Glob Oncol. 2016;2:154‐63.
- Borok M, Hakim J, Kutner J, Mawhinney S, Simoes E, Campbell T. Strategies to Improve Kaposi Sarcoma Outcomes (SIKO): an educational intervention in Zimbabwe. Cancer Control; 2014.
- Hemming K, Lilford R, Girling AJ. Stepped‐wedge cluster randomised controlled trials: a generic framework including parallel and multiple‐level designs. Stat Med. 2015;34:181‐96.
- Hussey MA, Hughes JP. Design and analysis of stepped wedge cluster randomized trials. Contemp Clin Trials. 2007;28:182‐91.
- Sessions M . Overview of the President's Emergency Plan for AIDS Relief (PEPFAR). 2021. [cited 2021 Jan 25] .
- Ely S, Gapara M, Lammersen K, Darden J, Borok M, Hosseinipour MC, et al. Pathology External Quality Assurance Program for Kaposi's Sarcoma International Clinical Trials AMC‐067/A5264 and AMC‐066/A5263. 15th International Conference on Malignancies in AIDS and Other Acquired Immunodeficiencies (ICMAOI). Bethesda, MD; 2015.
- Krown SE, Metroka C, Wernz JC. Kaposi's sarcoma in the acquired immune deficiency syndrome: a proposal for uniform evaluation, response, and staging criteria. AIDS Clinical Trials Group Oncology Committee. J Clin Oncol. 1989;7:1201‐7.
- Zurcher K, Mooser A, Anderegg N, Tymejczyk O, Couvillon MJ, Nash D, et al. Outcomes of HIV‐positive patients lost to follow‐up in African treatment programmes. Trop Med Int Health. 2017;22:375‐87.
- Fardhdiani V, Molfino L, Zamudio AG, Manuel R, Luciano G, Ciglenecki I, et al. HIV‐associated Kaposi's sarcoma in Maputo, Mozambique: outcomes in a specialized treatment center, 2010–2015. Infect Agent Cancer. 2018;13:5.
- Burger H, Ismail Z, Taljaard JJ. Establishing a multidisciplinary AIDS‐associated Kaposi's sarcoma clinic: patient characteristics, management and outcomes. S Afr Med J. 2018;108:1059‐65.
- Herce ME, Kalanga N, Wroe EB, Keck JW, Chingoli F, Tengatenga L, et al. Excellent clinical outcomes and retention in care for adults with HIV‐associated Kaposi sarcoma treated with systemic chemotherapy and integrated antiretroviral therapy in rural Malawi. J Int AIDS Soc. 2015;18:19929.
- Harris B, Goudge J, Ataguba JE, McIntyre D, Nxumalo N, Jikwana S, et al. Inequities in access to health care in South Africa. J Public Health Policy. 2011;32(Suppl 1):S102‐23.
- Goudge J, Gilson L, Russell S, Gumede T, Mills A. Affordability, availability and acceptability barriers to health care for the chronically ill: longitudinal case studies from South Africa. BMC Health Serv Res. 2009;9:75.
- Amerson E, Buziba N, Wabinga H, Wenger M, Bwana M, Muyindike W, et al. Diagnosing Kaposi's sarcoma (KS) in East Africa: how accurate are clinicians and pathologists? Infect Agent Cancer. 2012;7(Suppl 1):P6.
- Yaqub S, Stepenaskie SA, Farshami FJ, Sibbitt WL Jr, Fangtham M, Emil NS, et al. Kaposi sarcoma as a cutaneous vasculitis mimic: diagnosis and treatment. J Clin Aesthet Dermatol. 2019;12:23‐6.
- van Bogaert L‐J. Clinicopathological proficiency in the diagnosis of Kaposi's sarcoma. ISRN AIDS. 2012;2012:565463.
- Maskew M, Fox MP, van Cutsem G, Chu K, MacPhail P, Boulle A, et al. Treatment response and mortality among patients starting antiretroviral therapy with and without Kaposi sarcoma: a cohort study. PLoS One. 2013;8:e64392.
- Amerson E, Woodruff CM, Forrestel A, Wenger M, McCalmont T, LeBoit P, et al. Accuracy of clinical suspicion and pathologic diagnosis of Kaposi sarcoma in East Africa. J Acquir Immune Defic Syndr. 2016;71:295‐301.
- Slaught C, Williams V, Grover S, Bigger E, Kayembe M, Chiyapo S, et al. A retrospective review of patients with Kaposi's sarcoma in Botswana. Int J Dermatol. 2019;58:707‐12.
- Tsang MW, Kovarik CL. The role of dermatopathology in conjunction with teledermatology in resource‐limited settings: lessons from the African Teledermatology Project. Int J Dermatol. 2011;50:150‐6.
- Okuku F, Krantz EM, Kafeero J, Kamya MR, Orem J, Casper C, et al. Evaluation of a predictive staging model for HIV‐associated Kaposi sarcoma in Uganda. J Acquir Immune Defic Syndr. 2017;74:548‐54.
- Letang E, Lewis JJ, Bower M, Mosam A, Borok M, Campbell TB, et al. Immune reconstitution inflammatory syndrome associated with Kaposi sarcoma: higher incidence and mortality in Africa than in the UK. AIDS. 2013;27:1603‐13.
- Mosam A, Shaik F, Uldrick TS, Esterhuizen T, Friedland GH, Scadden DT, et al. A randomized controlled trial of highly active antiretroviral therapy versus highly active antiretroviral therapy and chemotherapy in therapy‐naive patients with HIV‐associated Kaposi sarcoma in South Africa. J Acquir Immune Defic Syndr. 2012;60:150‐7.
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