Purpose:  To evaluate the prevalence of undiagnosed and asymptomatic HIV infection in patients with ocular surface squamous neoplasia (OSSN) in an urban patient population in Malawi. Methods:  A consecutive series of patients presenting with OSSN was evaluated in an African academic centre. A detailed history and physical examination in 53 consecutive patients with conjunctival squamous cell carcinoma and conjunctival intraepithelial neoplasia were performed. Thirty‐eight (72%) patients agreed to undergo serological HIV testing. Results:  Seventy‐nine per cent (30 of 38) patients were HIV positive. None of the patients had previous HIV testing or was aware of having symptoms of HIV. Seventy per cent (n = 21) of the HIV‐positive patients had no other symptoms suggestive of HIV infection or any other disease. Patients were far more likely to refuse HIV testing if they were married and male. Conclusions:  The conjunctival tumour may be the primary and only apparent manifestation of HIV in patients presenting with OSSN in Sub‐Saharan Africa.

deoxyribonucleic acid (DNA) was positive from the conjunctival tumour and the facial papilloma.The total lymphocyte count was 1192/mm 3 , CD4 count was 182/mm 3 (15%), CD8 count was 603/mm 3 (50%), and CD4:CD8 ratio was 0.33. The dosage of immunosuppressive drugs was modulated over the next 6 months to bring CD4 counts within the normal range. The patient had no local tumour recurrence at 18-months follow-up. CommentThe pathogenesis of skin cancer in OTR is multifactorial, involving immunosuppression, oncogenic virus infection, and ultraviolet radiation. 1,3 Immunosuppression is considered a major causal risk factor, especially for HPV-induced malignancies. 4 CD4 lymphocytopenia, being associated with increased incidences of malignancies, may be an important marker. 5 There is a well-recognized causal relationship between HPV and squamous neoplasia of the uterine cervix. A similar causal relationship between OSSN and HPV has been suspected. 6 Postrenal transplantation, our patient was on long-term immunosuppression and had CD4 lymphocytopenia. He subsequently developed OSSN in the right eye and papilloma of the facial skin. Multifocality of OSSN as seen in our patient is a rare manifestation. 6 The OSSN as well as the skin papilloma were positive for HPV DNA by PCR, indicating that immunosuppression and CD4 lymphocytopenia may have predisposed to oncogenic HPV infection and subsequent development of OSSN. There is only one more case reported in the setting of immunosuppression following liver transplantation. 2 This patient, however, did not show evidence of HPV infection and manifested an aggressive tumour with orbital recurrence, intracranial extension, and tumour-related death. 2 The association of OSSN and postorgan transplantation immunosuppression appears causal, being mediated by oncogenic HPV infection. Systematic periodic ophthalmic evaluation of OTR may help in early diagnosis of subtle OSSN. AcknowledgementsWe have no financial interest in any of the methods or materials used in the study. 4 With a limited supply of antiretroviral drugs currently now available, there is an urgent need for research into the contribution conjunctival SCC could, or should make to the WHO staging, as well as the best preventative and therapuetic interventions for it in this setting. of the conjunctiva in my short article. I concentrated on super-infection as that was the subject I was given for my lecture and hence formed the basis of the article. Despite this it seems likely that SCC, given the much higher increased risk in HIV-positive people, is associated with an oncogenic infection in addition to ultraviolet radiation and immunosuppression. If this is true, then SCC would be a disease similar to Kaposi's sarcoma and anal neoplasia in being increased in HIV-positive people and associated with specific infections (HHV8 for KS and HPV for anal carcinoma). However, I feel that the perspective of SCC as gained from a specialist Eye Hospital will give a somewhat biased view of how common SCC is. Morgan et al 1 when des...