Sir,

In Evans's discussion of the impact of HIV on the management of eye disease,1 he omitted the commonest HIV-related disease presenting to eye departments in sub-Saharan Africa: squamous cell carcinoma (SCC) of the conjunctiva. HIV infection increases the risk of SCC 10-fold,2 and an epidemic of conjunctival SCC has been coincident with the HIV epidemic. The number of patients with conjunctival SCC exceeds all other ocular manifestations of HIV/AIDS treated at the Lion's Sight First Eye Hospital in Blantyre, Malawi. A proportion of patients present with recurrences, or at such a late stage that removal of the eye is required. In addition to the morbidity of SCCs, the burden of care for these patients removes time available for eye care professionals to dedicate to Vision 2020 goals. Evans's article focused on HIV-related superinfection; the conflicting evidence regarding conjunctival squamous neoplasia's association with human papilloma virus infection at least merits its inclusion.2, 3

Unlike Herpes Zoster, conjunctival SCC is not featured in WHO staging of AIDS used to consider eligibility for antiretroviral therapy in Malawi.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.