Travel Time from Cancer Center Is Associated with Disparities in Non-Hodgkin Lymphoma Diagnosis Among People Living with HIV in Malawi

Purpose: Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, serves a population of around ten million from the country’s Central and Northern regions. As one of just two centers in the country providing pathology and cancer care, the majority of the population is left with the burden of traveling long distances for diagnosis and treatment. HIV-associated non-Hodgkin lymphoma (NHL) is common in sub-Saharan Africa (SSA) due to the high prevalence of HIV in the region. Spatial barriers to care, particularly in relation to travel time, are not well defined in adults with HIV-associated malignancies in Malawi.

Methods: We included all patients with HIV-associated NHL from the KCH Lymphoma Study, a prospective observational cohort, from June 2013 to June 2023 (n=117). The location of study patients’ residence was mapped using QGIS with further descriptive and survivorship analyses, including demographic and clinical characteristics, conducted in R. AccessMod 5 was used to produce models of travel time to KCH, using assumptions from previous literature.

Results: The diagnoses included in this analysis were diffuse large B cell lymphoma (DLBCL) (n=79), Burkitt lymphoma (n=22), plasmablastic lymphoma (n=13), and primary effusion lymphoma (n=3). Estimated travel time to clinic varied significantly (range: 20-618 minutes). 48% of patients were from Lilongwe district which makes up only 10% of the population of the catchment area. We noted a significant negative relationship between mean travel time to KCH and reported incidence of HIV-associated malignancies (correlation= -0.015; p=0.009). Travel time varied significantly when disaggregated by HIV status, with HIV+ART- individuals tending to be resident closer to the cancer center than HIV- or HIV+ART+ patients (p=0.005). In addition to disparities in diagnosis, HIV-associated NHL patients had worse progression-free survival as travel time to clinic increased (p=0.02), which remained significant after controlling for known prognostic markers including stage, performance status, and lactate dehydrogenase.

Conclusion: Cancer care in Malawi is centralized, leading to diagnostic and treatment disparities. NHL patients who live further from KCH tend to face more challenges accessing diagnosis and treatment, particularly if they have comorbidities, such as HIV. Interestingly, the HIV+ ART- group tended to come from closer to KCH than other groups, implying that patients with curable lymphomas in more remote parts of the country are likely dying before they can be diagnosed and treated. Implementation science approaches are urgently needed to close the gap on both diagnostic and treatment disparities.