AIDS defining lymphomas in the era of highly active antiretroviral therapy (HAART) – An African perspective

The intermediate to high grade B-cell non-Hodgkin lymphomas are now one of three malignant AIDS defining conditions. The others being Kaposi’s sarcoma and cervical carcinoma. While co-infection with oncogenic agents including the human herpes 8 or Epstein-Barr virus offer targets in preventive treatment strategies for these AIDS defining lymphomas (ADL), administration of highly active antiretroviral therapy leading to immune reconstitution permits use of standard or even high-dose cytotoxic drug regimens with curative intent. It is not certain whether this should be done concomitantly or sequentially. Additional benefit may derive from infusional or high-dose chemotherapy regimens depending on the histological subtype while use of monoclonal antibodies such as rituximab or immunohaematopoietic stem cell transplantation needs to be further evaluated within controlled studies. Socio-economic considerations have an impact especially in resource limited settings while availability of tools for appropriate geno–phenotypic diagnosis and immunological monitoring such as the CD4 cell count will play an important role in the risk stratification as well as disease management. While it is generally accepted that the impact of HAART has an overall benefit both in incidence and treatment outcome in ADL, the expanded access to HAART programs are falling short of all targets in Africa. Accordingly focus is given to some of these controversies, including epidemiology, pathogenesis, clinical features, therapeutic options and ethical considerations.