The epidemic of HIV infection in sub-Saharan Africa, which bears the greatest burden, represents at least 70% of infected persons for 11% of the world's population, 75% of deaths and 90% of infections in children 12. A HIV-infected person may remain asymptomatic for 2 to 10 years or more. The occurrence of opportunistic infections in general is related to a significant decline in immune defenses and an increase in the viral load defining AIDS 3. Conjunctival squamous cell carcinoma like all tumor diseases presents itself as an opportunistic infection. A classification of the CDC 1993 determines a correlation between the CD4 cell count and the clinical course of AIDS 4. Unfortunately, in sub-Saharan Africa, particularly in Côte d'Ivoire, it is not easy to get the assay of CD4 cell count in patients living with HIV who arrive in hospitals completely impoverished. In our study only 27 out of 54 patients were able to perform the assay of CD4 cell count.

The objective of our study is to establish an epidemiological and clinical profile of squamous cell carcinoma of conjunctiva (SCC) in patients living with HIV and to assess its evolutionary characteristics in these HIV positive subjects.

We carried out a descriptive cross-sectional study over a period of 4 years from January 2012 to December 2016 in the ophthalmology department of the University Hospital of Treichville. It involved 23 patients.

This study included HIV positive patients who consulted during the period and presented a conjunctival tumor with or without local-regional and cerebral invasion and with a histological diagnosis of epidermoid carcinoma. The data collection included the following elements of the history (age, gender, onset of the symptomatology, Personal and family history), clinical signs and evolution, ophthalmological and radiographic (tomodensitometry) elements.

The pathological diagnosis is obtained after analysis of biopsy incision fragment or surgical excision specimen and enucleation or even exenteration. All surgical procedures are performed under general anesthesia. Samples were fixed with formalin before being sent to the pathology department. HIV-AIDS serology was performed after informed consent of patients, in some cases with the typing of CD4-lymphocytes. Adjuvant or neoadjuvant topical or general chemotherapy has sometimes been used. The statistical analysis was carried out by the Epi-info version 6.0 Software and a statistical comparison using the Chi2 test with a significance threshold set at 5%.

All 23 patients presented invasive differentiated squamous cell carcinoma (Figure 3). None in situ carcinoma was found.

Squamous cell carcinoma of conjunctiva has also been found to occur in patients aged less than 50 years of age. This is also shown in your study5. We did not find any real gender predominance (sex ratio in the literature is 1) 6, although in our study the sex ratio was in favor of the female gender with 0.92 that is 52%. Several authors, including Imdary 7 and Caujolle 8, have found a male predominance. This finding in sub-Saharan Africa could be explained by the tendency to feminize HIV infection with 6.4% compared to 2.9% of seroprevalence in humans 9. Indeed, HIV infection as well as prolonged solar exposure and HPV (human papilloma virus) infection are unanimously recognized as risk factors 10 especially in tropical Africa. This female population represents the population most exposed to all kinds of abuses (sexual, polygamous and agricultural activities..) in Africa where they assist men to this day. This observation of the predominance of the female sex in the occurrence of the SCC in HIV-positive subjects was also made by Kaimbo Wa Kaimbo et al. 11 in the Congo and by Makupa et al. 12 in Tanzania who found 70% and 62.2%, respectively. HIV induces chronic suppression of the immune system, hence anti-cancer immunity, which increases the oncogenic potential especially in cases of dysplasia 1314. Moreover, this acquired immunosuppression is responsible for severe forms of SCC. In our study 70% of patients were seen with orbital tumor associed exophthalmos and 35% of eyes present functional eye loss. Indeed, the prevalence of SCC in patients living with HIV according to Chisi et al 15 is 7.8% in Kenya. In our study we were unable to establish this prevalence, however a large majority of patients received in consultation were HIV-positive, which immediately introduced a bias in our sampling. The severity of the clinical forms is correlated with a low CD4 cell count. According to Place et al., Bekele S. and al.1617, squamous cell carcinoma would occur early in patients living with HIV, and when this status is associated with a low CD4 cell count, the prognosis would prove to be poor because these patients seem to succumb to their HIV status rather than squamous cell carcinoma. This important immune depression would be related to a delayed diagnosis, a denial of the disease and the increased precariousness of the populations which creates a brake on their management. As for the influence of the type of HIV on the forms, our study did not establish a correlation between the severity of the forms of SCC and the serotype. On the other hand, we have noted, as in the literature, a clear predominance of HIV 1 on the associated forms and on HIV 2. Indeed, according to a UN-AIDS report, HIV 1 is the dominant serotype in sub-Saharan Africa where more than 2/3 of HIV-infected patients are infected with HIV 1.

The severity of clinical and histopathologica forms maked the management difficult in our context without, cryotherapy, radiotherapy. Most tumors underwent a biopsy excision with pathological examination of the surgical specimen. Six patients were treated with adjuvant chemotherapy. Other treatments have been proposed in the literature and appear to have a beneficial effect: Interferon alpha-2a as alternative treatment18, chemoreduction of the tumor prior to surgery in advanced cases with orbital extension 19 fractionated strontium-90 radiation in a population with a high prevalence of HIV20.

The prognosis remains reserved with 5 cases of recurrence, 3 cases of death. The average follow-up was 18 months. Six patients underwent chemotherapy in register of cancer (cancerology). We noted five cases of recurrence, 8 were lost to follow-up (35%) and 3 deaths occurred during the study. The prognosis of SCC remains poor in our study. The patients who died on adjuvant chemotherapy course had a very involves forms (figure 2) with positive surgical margin. In additional they were VIH positive with CD4 rate below 200 cel/mm3. Penoloppe found higher death rates with 26 patients evaluated over 6 years , therefore, study noted low rate of lost to follow up21. In this study we can established relationship between SCC extended forms and rate low rate of CD4 lymphocyte.

HIV epidemic contributes to the occurrence of a variety of so-called opportunistic infections such as cancer diseases among which conjunctival squamous cell carcinoma is readily mentioned and whose severity would be correlated with the level of CD4 lymphocytes. The prevention of invasive SCC involves sensibilization, screening of patients with suspicious of conjunctival tumors and above all, localized SCC confirmed must be taken care optimally.