Sources of Diagnostic Delay for HIV-Associated Lymphoma in a Fine Needle Aspiration Clinic in Soweto, South Africa

Abstract

PURPOSE Fine needle aspiration (FNA) is an important diagnostic modality used in the evaluation of lymphadenopathy in people living with HIV (PWH) to differentiate between tuberculosis (TB) and lymphoma. However, an FNA suggestive of lymphoma is generally not sufficient for diagnosis and needs to be confirmed by biopsy. We evaluated time to diagnosis for PWH with FNA findings suggestive of lymphoma in Soweto, South Africa. METHODS PWH with lymphadenopathy presenting to an FNA clinic in Soweto, South Africa were enrolled in a prospective observational study between September 2021 to December 2022. Participants were interviewed at initial presentation to the FNA clinic and prospectively followed for 8 months or until death. Patient intervals (PI) and healthcare practitioner intervals (HPI) were obtained and descriptive statistics performed. RESULTS Among 146 PWH, 20 participants had FNA cytology suggestive of lymphoma and one participant was ultimately diagnosed with lymphoma although the initial FNA showed reactive adenopathy. The median age for these 21 participants was 46 years (IQR: 38 - 51) with a male predominance (67%). The median CD4 count was 213 (IQR 137 - 304) and 7/20 (35%) had an undetectable viral load. Biopsy confirmation of lymphoma occurred in 11/21 participants, while 8/21 died prior to biopsy confirmation and 2/21 completed 8 months of follow-up alive without biopsy confirmation. Additionally, 2/11 diagnosed with lymphoma died within 2 weeks of diagnosis. The PI was evaluable for 15 participants and was a median of 30 days (IQR 11-71). The HPI was a median of 88 days (IQR 55-134). First presentation with symptoms was to a clinic (10/21; 48%), pharmacy (8/21; 38%), or traditional healer (3/21; 14%). The median clinic visits prior to FNA was 2 (IQR: 2-3). For those that died, there was a trend towards a longer PI, first presentation to either the pharmacy or a traditional healer, and a median total visits prior to FNA. CONCLUSION Sources of diagnostic delay for the diagnosis of HIV-associated lymphoma include initial presentation to a non-healthcare practitioner, prolonged median HPI, and non-standardized process of referral for evaluation of lymphadenopathy. Interventions to improve the diagnostic triage are warranted.