Abstract
BackgroundCryptococcal meningitis is a leading cause of death amongst people living with HIV. However, routine cryptococcal antigen (CrAg) screening was not in the national guidelines in Eswatini.ObjectivesA cross-sectional study was conducted between August 2014 and March 2015 to examine CrAg prevalence at Mbabane Government Hospital in Eswatini.MethodsWe collected urine and whole blood from antiretroviral-therapy-naïve patients with HIV and a cluster of differentiation 4 (CD4) counts < 200 cells/mm3 for plasma and urine CrAg lateral flow assay (LFA) screening at the national HIV reference laboratory. Two CD4 cut-off points were used to estimate CrAg prevalence: CD4 < 100 and < 200 cells/mm3. Sensitivity and specificity of urine CrAg LFA was compared to plasma CrAg LFA.ResultsPlasma CrAg prevalence was 4% (8/182, 95% confidence interval [CI]: 2–8) amongst patients with CD4 counts of < 200 cells/mm3, and 8% (8/102, 95% CI: 3–15) amongst patients with CD4 counts of < 100 cells/mm3. Urine CrAg LFA had a sensitivity of 100% (95% CI: 59–100) and a specificity of 80% (95% CI: 72–86) compared with plasma CrAg LFA tests for patients with CD4 < 200 cells/mm3. Forty-three per cent of 99 patients with CD4 < 100 were at World Health Organization clinical stages I or II.ConclusionThe prevalence of CrAg in Eswatini was higher than the current global estimate of 6% amongst HIV-positive people with CD4 < 100 cell/mm3, indicating the importance of initiating a national screening programme. Mechanisms for CrAg testing, training, reporting, and drug and commodity supply issues are important considerations before national implementation.
Highlights
Cryptococcosis, caused by Cryptococcus neoformans or Cryptococcus gattii, is an invasive and lifethreatening fungal infection, often affecting immunocompromised patients
Cryptococcal meningitis, a type of cryptococcosis affecting the brain meninges, is one of the leading opportunistic infections and causes of death amongst people living with HIV
This study is relevant in the context of recent World Health Organization (WHO) guidelines on managing advanced HIV disease, rapid initiation of antiretroviral therapy (ART),[1,9] and the current recommendation to include cryptococcal antigen (CrAg) screening in national guidelines in Eswatini[12] and in other countries.[13]
Summary
Cryptococcosis, caused by Cryptococcus neoformans or Cryptococcus gattii, is an invasive and lifethreatening fungal infection, often affecting immunocompromised patients. Cryptococcal meningitis, a type of cryptococcosis affecting the brain meninges, is one of the leading opportunistic infections and causes of death amongst people living with HIV. It especially affects patients with advanced HIV who have a cluster of differentiation 4 (CD4) count < 200 cells/mm[3] or who are at stages III or IV of the World Health Organization (WHO) HIV infection clinical stages.[1] In 2014, globally, the cryptococcal antigenaemia prevalence was estimated at 6% (278 000) amongst patients with CD4 < 100 cells/mm[3], with approximately 223 100 cryptococcal meningitis cases occurring annually.[2] In the same year, 2014, the annual deaths due to cryptococcal meningitis were estimated at 181 100, with 75% (135 900) of deaths occurring in sub-Saharan Africa.[2]. Routine cryptococcal antigen (CrAg) screening was not in the national guidelines in Eswatini
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