Antiretroviral therapy, cancer prevention and care in Africa The experience of the IeDEA West Africa Collaboration Pr Francois Dabis and Dr Antoine Jaquet Institute of Public Health, Epidemiology & Development (ISPED), Bordeaux University

2 IeDEA International Epidemiologic Databases to Evaluate AIDS International research consortium established in 2005 by the US National Institute of Allergy and Infectious Diseases (NIH) Resource for globally diverse HIV/AIDS data To address research questions in HIV/AIDS unanswerable by single cohorts First round ; Second round : currently year 9: July 2014 to June 2015

3 IeDEA Regions

4 WADA: 17 adult and 11 pediatric centres in 10 countries Benin, Burkina Faso, Côte d’Ivoire, Ghana, Guinea, Guinea-Bissau, Mali, Nigeria, Senegal, Togo Coordinating Center: ISPED, Univ Bordeaux, France Regional Office: PAC-CI, CHU Treichville, Abidjan Côte d’Ivoire IeDEA West Africa (WADA)

5 WADA Objectives (1) To measure the effectiveness of ART in HIV-infected individuals in West Africa in the long-term, and to assess factors that influence program and treatment outcomes

6 WADA Objectives (2) To measure the effectiveness of ART in HIV-infected individuals in West Africa in the long-term, and to assess factors that influence program and treatment outcomes To increase the capacity for delivering ART durably in West Africa by increasing the capacity for monitoring clinical outcomes at the individual and population levels in adults and children

7 WADA Objectives (3) To measure the effectiveness of ART in HIV-infected individuals in West Africa in the long-term, and to assess factors that influence program and treatment outcomes To increase the capacity for delivering ART durably in West Africa by increasing the capacity for monitoring clinical outcomes at the individual and population levels in adults and children To document the morbidity burden in HIV-infected individuals in care in HIV programs throughout West Africa to look for prevention and care solutions

8 WADA study design Observational prospective multi-center cohort Pooled database of HIV-infected adults and children data followed in reference clinics in West Africa Additional surveys to address specific questions / specific populations With a focus on cancer in people living with HIV

9 Current WADA merger Retrospective and prospective cohort HIV-infected adults on ART N= 59,941 HIV-2 or (HIV-2 and HIV-1) positive N= 4,818 HIV-exposed children N= 2,819 HIV-infected children without ART N= 1,775 HIV-infected children with ART N= 4,899

Context How routinely collected data can help addressing priority research questions in the area of HIV-related malignancies in West Africa? – No routine data collection on cancer and its risks factors available among HIV-infected patients – Sparse functional cancer registries – No national death registries and no national identification number Need to document HIV-related malignancies and their risk factors in West Africa using appropriate approaches 10

Studying cancer risk factors Dedicated prevalence studies in WADA participating clinics Alcohol and tobacco use in HIV-infected patients Jaquet et al. Int J Tub Lung Dis, 2009 Jaquet et al. Addiction, 2010 – Documented the diversity of substance abuse across different countries using standardized & reproducible tools – Perspectives Enables the extension of this approach In other IeDEA regions Over time in the same sites to identify trends Minimal data collection for clinical use? 11

HIV-related malignancies (1) Cancer of the cervix & precancerous lesions – Cancer of the cervix sufficiently frequent and eligible to an affordable preventive approach including screening and early treatment – Operational characteristics related to the screening in HIV-positive women were documented (Horo et al. BMC Public Health 2012) – Factors associated with precancerous lesions among ART-treated HIV- positive women were investigated (Jaquet et al. Plos One 2014) – Perspectives Follow-up of initially screened women to assess the incidence of new lesions as well as recurrent lesions in previously treated women Integration in routine HIV care? 12

HIV-related malignancies (2) How to document less common HIV-related malignancies? Extend the WADA network to cancer referral centers HIV and cancer in referral hospitals from four West African countries – Systematic collection of HIV status in patients with a malignant condition attending clinical wards from participating referral hospitals – Allowed the comparison of HIV seroprevalence in selected cancers known or suspected to be linked to HIV to a referent group of patients with malignant conditions unrelated to HIV – To be presented in the following session “Beyond Control of HIV: Comorbidities and Coinfections around the World” on Wednesday 16:30 (Melbourne Room 1) 13

Conclusions The WADA network allowed the collection of various cancer risk factors and precancerous conditions amenable to prevention strategies in West Africa – Particularly important in a context of unaffordable therapeutic approach for cancer with advances stages Limitations – Unable to collect reliable and detailed information of invasive malignancies in HIV cohorts as morbid events Perspective – Initiate prospective sub-cohorts of “high-risk populations” within the WADA collaboration focusing on selected types of cancers Ex: “Hepatocarcinoma among HIV/HBV co-infected cohorts” 14

Acknowledgments All patients & medical staff that participated to the cancer studies HIV & Cancer studies coordinators & investigators Bordeaux: E Balestre, A Sasco Benin: J Akakpo, J Sehonou, DM Zannou Côte d’Ivoire: A Tanon, A. Attia, SP Eholie, E. Bissagnene Nigeria: E Oga, M Odutola, E Jedy-Agba, M Charurat, C Adebamowo Togo: DK Ekouevi, B Goilibe PACCI regional center for data management : TA Azani, P Coffie & colleagues WADA PIs: E Bissagnene & F Dabis