November 7, 2008
In a poster presentation at the joint 2008 ICAAC/IDSA meeting in Washington, DC, a recent study described a peculiar type of Kaposi's Sarcoma (KS) beginning to emerge in healthy people with HIV. These individuals report higher CD4 counts (>300) and lower (<300) or undetectable viral loads, and yet show signs of this herpes-related cancer. The poster detailed the conditions under which this has been seen in health care settings. It confirms the reports from other cohorts of patients with similar signs of KS disease.
Early in the epidemic, KS was one of the most common symptoms of HIV disease with its characteristic signs of purple lesions on the skin. Itposed a serious health threat to those living with HIV, and quickly became an AIDS-defining condition in the 1980s. It is caused by HHV8, or human herpesvirus 8.
Typically appearing as red, purplish, brown or black bumps or blotches on the legs, face and genitals, KS can also spread internally through the stomach, intestines and respiratory system. Before HAART, a case of KS signaled a very weak immune system, often with CD4 counts below 150 and viral loads above 10,000. Although KS often is not painful, advanced disease can produce swelling and pain.
Over the past decade, HAART has improved the health and lives of people with AIDS, often keeping many of the more serious infections from becoming life-threatening situations. This includes KS, and its incidence has greatly decreased since 1996.
This retrospective study (11/04 to 07/08) conducted by the University of California San Francisco culled data on 10 gay men with signs of KS despite having healthy immune systems. CD4 counts averaged above 300 and viral loads below 300. The average age was 59, time living with HIV was 17 years, and time living with KS was 2.5 years. KS biopsies were prospectively performed.
Of the 10, 9 had at least one KS lesion on their lower limbs, and 7 only had lesions there. One had a lymph node involved while 3 had mild swelling. Two reported pain from lesions on their feet. None had internal KS, and none have developed it since. Nine were on HAART when diagnosed with KS, and all are currently on HAART.
Among those who did not undergo treating their KS, the disease has remained fairly stable. Of those who took therapy, it included surgical removal, radiotherapy, topical alitretinoin, intralesional vinblastine, or liposomal doxorubicin. All of these treatments have shown mild to moderate improvement in symptoms. None have faced eruptive KS or organ disease or have had other opportunistic infections.
Although the study's purpose was to collect the clinical symptoms and markers of this type of KS disease, the poster went so far to state that: "it is our recommendation that they should be managed conservatively". It stated that a person's adherence to HAART could be revisited to improve its effectiveness in controlling the KS. Also, it appears that protease inhibitors do not offer any more benefit over NNRTIs in treating this type of KS.
Prior to the AIDS epidemic two types of KS were seen. The first type affected older men, usually from the Mediterranean region. This form was slow, non-aggressive and rarely led to serious health complications. The second affected mostly young African boys and was typically aggressive -- spreading and causing disease rapidly.
Unlike the KS seen among people with HIV in the 1980s, these men show symptoms that persist yet are not aggressive, invasive or lethal. This type of KS appears more like the type affecting older Mediterranean men. Taken together with the data from other recent cohorts (Chan et al, Nasti et al, Martinez et al, and Krown et al), this study's observations perhaps show a changing landscape in KS disease. This may well call into question other emerging issues of aging with HIV disease.