Increased mortality among HIV infected patients with cryptococcal antigenemia in Guinea-Bissau.

Ditte Thomsen,Sanne Jespersen,Lars Østergaard,Alex Lund Laursen,Christian Erikstrup,Christian Wejse,David Da Silva Té,Faustino Gomes Correira,Bo Langhoff H�Nge,Candida Medina,Cecilie Juul Hviid

doi:10.11604/pamj.2018.29.18.14099

Abstract

Cryptococcal antigenemia may precede development of cryptococcal meningitis and death among patients with advanced HIV infection. Among 200 retrospectively and randomly selected ART-naïve patients with CD4 counts < 100 cells/μl from Guinea-Bissau, 20 (10%) had a positive cryptococcal antigen test. Self-reported headache and fever were predictors of a positive test, while cryptococcal antigenemia was a strong predictor of death within the first year of follow-up, MRR 2.22 (95% CI: 1.15-4.30). Screening for cryptococcal antigenemia should be implemented for patients with advanced HIV in Guinea-Bissau. Pre-emptive anti-fungal therapy should be initiated prior to ART-initiation if the screening is positive.

Highlights

Cryptococcal meningitis (CM) is a severe opportunistic infection among HIV-infected patients and is estimated to cause almost 625.000 deaths each year globally
Baseline characteristics and factors associated with cryptococcal antigenemia: Among 200 randomly selected ARTnaïve patients with a CD4 count < 100 cells/μl, 20 (10%) had a positive Cryptococcal antigen (CrAg) test with a median titer of 1:400
Cryptoccal antigenemia was a strong predictor of death among CrAg positive patients with a mortality rate ratio (MRR) of 2.22 and an even stronger predictor of death among patients with a CrAg titer diluted more than 5 times (> 1:5), MRR 2.48

Summary

Introduction

Cryptococcal meningitis (CM) is a severe opportunistic infection among HIV-infected patients and is estimated to cause almost 625.000 deaths each year globally. The prevalence of cryptococcal antigenemia among HIV-infected patients has been described in several African and Southeast Asian countries, with a prevalence ranging from 1-19%, the highest prevalence found among patients with low CD4 counts [3]. One study has described the prevalence of cryptococcal antigenemia among a smaller group of HIV-infected individuals in Guinea-Bissau and found a prevalence of 1% among patients with a median CD4 count of 185 cells/μl [4]. The WHO recommends the use of CrAg screening in antiretroviral therapy (ART)-naïve patients with a CD4 count < 100 cells/μl in populations with a high prevalence of cryptococcal antigenemia (prevalence > 3%). The aim of this study was to investigate the prevalence of cryptococcal antigenemia, risk factors for antigenemia and examine cryptococcal antigenemia as a risk factor for mortality among patients with advanced HIV-infection in Guinea-Bissau, to provide data to guide decision on CrAg screening

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