Spectrum and Immunovirological Determinants of Tumours Among People Living with HIV in Uganda: A Retrospective Cohort Study from a Specialised HIV Centre, 2017 to 2026

BackgroundSub-Saharan Africa carries a disproportionate burden of HIV-associated malignancies, yet the contemporary tumour spectrum in the dolutegravir (DTG) era and the immunovirological context at cancer diagnosis remain incompletely characterised in East African routine HIV-care settings. We sought to describe the spectrum, malignant fraction, and immunovirological determinants of neoplasms diagnosed at a specialised HIV centre in Kampala, Uganda. MethodsWe conducted a retrospective cohort analysis of 220 tumour records from 217 unique people living with HIV (PLHIV) registered at Mildmay Hospital between November 2017 and January 2026. Tumours were classified by ICD-10 disease group and malignancy status (benign/malignant). Bivariate associations with malignancy status were tested using {chi}2 or Fisher exact tests for categorical variables and Mann-Whitney U tests for continuous variables ( = 0.05). Crude odds ratios (OR) with 95% confidence intervals (CI) were computed for selected dichotomous comparisons. ResultsThe cohort had a median age of 47 years (IQR 39-54) and was 58.2% female. Overall, 138/220 tumours (62.7%) were malignant. Kaposi sarcoma (KS) was the most frequent malignancy (n=65; 47.1% of all malignant cases), followed by haematopoietic malignancies (n=32; 23.2%) and malignant gynaecological tumours (n=10; 7.2%). Among 156 patients with viral load data, 134 (85.9%) were virally suppressed at tumour diagnosis, yet 70/134 (52.2%) of those suppressed patients had a malignant tumour. Advanced WHO clinical stage (III/IV) at ART initiation was strongly associated with malignant diagnosis (39/86 [45.3%] versus 9/79 [11.4%]; OR 3.53, 95% CI 1.59-7.84; p=0.002). Median CD4 at ART initiation was markedly lower in malignant compared to benign tumour patients (147 vs 476 cells/{micro}L; p<0.001), and median ART duration was substantially shorter (37 vs 102 months; p<0.001). KS patients had significantly lower CD4 (136 vs 269 cells/{micro}L; p=0.002) and shorter ART duration (4 vs 86 months; p<0.001) than patients with other malignancies. Malignancy did not differ across DTG-, EFV-, and PI-based regimens (p=0.992). ConclusionsHIV-associated tumours in this Ugandan cohort remain predominantly malignant and dominated by KS, even against a backdrop of high viral suppression rates. The clustering of malignancy among patients with low pre-ART CD4 counts and advanced WHO stage points to incomplete immune reconstitution, persistent oncoviral co-infection, and residual inflammation as mechanistic targets. These data establish the scientific platform for a prospective HIV-oncology cohort at Mildmay Hospital and Mildmay Research Centre and inform context-appropriate cancer screening and surveillance priorities.