HIV-associated Kaposi sarcoma — DTM&H MCQ

Correct answer: C — Initiation of ART as first-line management

The correct answer is C, initiation of ART as first-line management. The clinical and histological picture (painless violaceous plaques on skin and palate in a patient with advanced HIV, CD4 35, biopsy showing spindle cells with slit-like vascular spaces) is diagnostic of HIV-associated Kaposi sarcoma, driven by HHV-8 in the setting of severe immunosuppression. Current guidance is unanimous that for mild to moderate disease, immune reconstitution with ART is the essential first step, since restoring CD4 function commonly produces lesion regression and reduces KS-related mortality independent of any local therapy. Local or systemic anti-tumour treatments are reserved as adjuncts for extensive, symptomatic, or visceral disease, not as the primary intervention, and none of them address the underlying immunodeficiency driving tumour proliferation. Why the other options are wrong: B. Surgical excision of skin lesions: KS is typically multifocal and often recurs at new or adjacent sites; excision does not address the underlying immune defect and is not used as primary management. A. Intralesional vincristine alone: this is a symptomatic option for isolated cosmetically troublesome lesions, not a substitute for ART, and does not alter systemic disease progression. D. Radiotherapy to skin lesions only: useful for localised, bulky or cosmetically sensitive lesions but is palliative and site-limited, leaving untreated immunosuppression to drive new lesion formation elsewhere. E. Topical 5-fluorouracil: has no established efficacy in HIV-associated KS and is not part of any recognised treatment pathway. Key point: in HIV-associated Kaposi sarcoma, ART-driven immune reconstitution is the cornerstone of treatment, with chemotherapy or radiotherapy reserved as adjuncts for advanced, symptomatic, or visceral disease.

Reference: WHO Guidelines on the Management of Advanced HIV Disease (2025 update), Kaposi sarcoma section (consistent with BHIVA Guidelines for HIV-associated Malignancies, British HIV Association): ART is confirmed as first-line treatment for all HIV-associated Kaposi sarcoma, with immediate ART initiation recommended for mild to moderate disease. https://www.ncbi.nlm.nih.gov/books/NBK620059/