FACTORS ASSOCIATED WITH LATE PRESENTATION OF SYMPTOMATIC CANCERS AMONG HIV INFECTED PERSONS IN JOS, PLATEAU STATE

TABLE OF CONTENTS

Title Page

Summary

Table of Contents

List of Acronyms

Chapter One - Introduction

1.1       Background

1.2       Problem Statement

1.3       Justification of Study

1.4       Research Questions

1.5       General and Specific Objectives

1.5.1 General Objectives

1.5.2 Specific Objectives

Chapter Two - Literature Review

2.1       HIV Infection and Type of Cancers

2.2 Late Presentation of Cancer

2.3       Socio-demographic Factors

2.4       Patient Mediated Factors

2.5       Health Service Factors

Chapter Three - Material and Methods

3.1       Description of Study Area

3.2       Study Design

3.3       Study Period

3.4       Study Population

3.4.1 Inclusion Criteria

3.4.2 Exclusion Criteria

3.4.3 Definition of late presentation of cancer

3.4.4 Sample Size Determination

3.5. Sampling Technique

3.6. Study Instrument

3.7. Data Collection Technique

3.8       Quality Assurance Procedures

3.8.1 Pilot Study

3.8.2 Training of Field Worker

3.9. Data Management

3.9.1 Data Collections and retrieval

3.9.2 Measurement of Variables

3.9.3 Statistical Analysis

3.9.4 Criteria used in assessing delay

3.10 Ethical Consideration

3.11. Limitation (and efforts made to reduce the effect of limitations)

3.12. Scope of the Study

3.13 Dissemination Plan

Chapter Four - Result

Chapter Five - Discussion

Chapter Six – Conclusion and Recommendation

6.1 Conclusion

6.2 Recommendation

References

Appendices

SUMMARY

Cancer is a disease defined to be a tissue growth that continues even after cessation of the stimulus that first evoked it. The cancer symbol is synonymous with the animal "Crab" which has many fingers depicting the multidirectional spread of the disease. Late presentation is the most important factor responsible for high morbidity and mortality due to cancer in Nigeria. Site based studies show the proportion of late stage presentation range between 60-92% in the last 10years. It is predicted that by 2020, new cases of cancer in the world will increase to over 15 million while deaths attributable to cancers about 12 million. Much of the burden of cancer morbidity and mortality will occur in the developing world because of cancer associated infectious diseases of which HIV infection carries a large proportion and late diagnosis of cancer. Nigeria has the second highest HIV burden worldwide, Plateau State ranked 6th in the country sentinel survey of the year 2010.

A mixed method study consisting of quantitative and qualitative component, was carried out and data collected. Variables on type of cancer, Patient and health service factors associated with late presentation of cancers among the respondents were carried out. Quantitative data was analyzed using Epi-info version 3.5.3 and Microsoft Excel while thematic analysis was done for qualitative data.

There were 503 respondents, males 252(50.1%) and females 251(49.9%). The mean age was 48.7±13.5years. Majority 432(85.9%) of the respondents were married and only 71(14.1%) were single. Approximately 362(74%) of the respondents were self-employed and 141(26%) were government workers. Among the respondents, 401(93%) of them had some education while 37(7.4%) of respondents have not had any formal education. Logistic regression of socio-demographic factors and late presentation of cancer indicated that there was a significant association between Age range 36-45 years OR 2.7, (P=0.0005), Male sex OR 2.5, (P=0.002), Farming occupation OR 1.7, (P=0.0005) and Primary education OR 2.0, (P=0.0005) status of respondents. Religious affiliation was not a significant factor. Kaposi sarcoma 173(31.63%) was the commonest occurring cancer among the respondents. Majority of respondents 349(69%) presented more than six months after onset of symptom. There Initial reaction to health issues was mainly the use of Alternative remedies 234(46.5) CI 42.1-51.0. The most frequent symptoms among respondents was pain 462(45.70%) followed by swelling 237(23.44%) and skin changes 210(20.77). Waiting time to obtain histological diagnosis from time of presentation to health facility was mainly 3-6months 274(54.47%). Laboratory related issues 199(39.56%) and Long booking time 163(32.40%) were the most common reasons for delay in initiating treatment.

Delay occurred at three phases in the study, First was the interval between the patient first noticing a symptom and first consulting a doctor, Second, between first consultation and obtaining histological diagnosis and Third between diagnosis and referral or initiating treatment. In addition to outlining the various points during which factors have influenced time to presentation and referral, considering delay in these phases has enabled identification of areas where interventions can be designed to reduce delay.

CHAPTER ONE - INTRODUCTION

1.1         Background

Cancer is becoming one of the leading causes of increased morbidity and mortality worldwide. It is predicted that by 2020, new cases of cancer in the world will increase to over 15 million while deaths attributable to cancers about 12 million.¹ Much of the burden of cancer morbidity and mortality will occur in the developing countries because of the tilt to industrialization, change in diet from high roughages to refined foods with a sedentary life style, increased tobacco use as well as the compounding burden of cancers associated with infectious diseases of which HIV infection carries a large proportion.²

Nigeria has the second highest number of people living with HIV/AIDS in the world, with 1000 new cases of infection daily and 217,148 related deaths, one third attributed to cancers.³

Cancers associated with HIV infection are classified into AIDS defining and Non AIDS defining. The exact mechanism by which these cancers occur is not well understood but they are associated with low immunity measured in the blood as the "Cluster of Differentiation" 4 and 8 cells (CD4 and CD8 cell counts). AIDS defining cancers are

Kaposi sarcoma, Non Hodgkin‟s lymphoma and cervical cancer.⁴ Non HIV associated cancers refers to any other cancer outside the three in an HIV infected person. Although there is scarcity of information on the prevalence of various cancers among HIV infected persons in Nigeria, studies evaluating incidence of cancers among HIV infected individuals show a 1.7 to 3 fold increased incidence of non AIDS defining malignancies among HIV infected individuals than general population irrespective of being on Highly Active Antiretroviral therapy (HAART)...

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