A multicenter survey of asymptomatic cryptococcal antigenemia among patients with advanced HIV disease in Nigeria

Rita O Oladele; Alexander M Jordan; Joy U Okaa; Iriagbonse I Osaigbovo; Shuwaram A Shettima; Nathan Y Shehu; Adeyinka A Davies; Yahaya Mohammed; Mary A Alex-Wele; Garba Iliyasu; Jude C Nwaokenye; Samuel A Fayemiwo; Ubong A Udoh; Titilola Gbajabiamila; David W Denning; Tom M Chiller

doi:10.1371/journal.pgph.0001313

A multicenter survey of asymptomatic cryptococcal antigenemia among patients with advanced HIV disease in Nigeria

PLOS Glob Public Health. 2023 Jan 31;3(1):e0001313. doi: 10.1371/journal.pgph.0001313. eCollection 2023.

Authors

Rita O Oladele^{1

2}, Alexander M Jordan³, Joy U Okaa⁴, Iriagbonse I Osaigbovo⁵, Shuwaram A Shettima⁶, Nathan Y Shehu⁷, Adeyinka A Davies⁸, Yahaya Mohammed⁹, Mary A Alex-Wele¹⁰, Garba Iliyasu¹¹, Jude C Nwaokenye¹², Samuel A Fayemiwo¹², Ubong A Udoh¹³, Titilola Gbajabiamila¹⁴, David W Denning¹⁵, Tom M Chiller³

Affiliations

¹ Department of Medical Microbiology and Parasitology, College of Medicine University of Lagos, Lagos, Nigeria.
² Medical Mycology Society of Nigeria, Lagos, Nigeria.
³ Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control, Atlanta, Georgia, United States of America.
⁴ Department of Pharmaceutical Microbiology and Biotechnology, Nnamdi Azikiwe University, Awka, Nigeria.
⁵ Department of Medical Microbiology, University of Benin Teaching Hospital, Benin City, Nigeria.
⁶ Department of Medical Microbiology, Parasitology and immunology, Modibbo Adama University Teaching Hospital, Yola, Nigeria.
⁷ West African Centre for Emerging Infectious Disease, Jos University Teaching Hospital, Jos, Nigeria.
⁸ Department of Medical Microbiology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria.
⁹ Department of Medical Microbiology and Parasitology, Faculty of Basic Clinical Sciences, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria.
¹⁰ Department of Medical Microbiology and Parasitology, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria.
¹¹ Infectious Disease Unit, Department of Medicine, College of Health Sciences, Bayero University, Kano, Nigeria.
¹² Department of Medical Microbiology and Parasitology, University College Hospital, Ibadan, Nigeria.
¹³ Department of Medical Microbiology and Parasitology, University of Calabar, Calabar, Nigeria.
¹⁴ Clinical Sciences Department, Nigerian Institute of Medical research, Lagos, Nigeria.
¹⁵ Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom.

Abstract

As of 2018, cryptococcal antigen (CrAg) screening in patients with advanced human immunodeficiency virus (HIV) disease (AHD) was not routinely implemented in Nigeria despite being recommended in the national HIV treatment guidelines. Our aim was to determine the prevalence and risk factors for asymptomatic cryptococcal antigenemia in adult people living with HIV (PLHIV) in Nigeria to advocate for the implementation of routine CrAg screening. A descriptive cross-sectional study and CrAg screening of consecutive adult PLHIV with CD4 counts ≤200 cells/μL was conducted from April 2018 to April 2019 at HIV clinics in eleven tertiary hospitals spread across Nigeria's six geopolitical regions. Prevalence of asymptomatic cryptococcal antigenemia was estimated by facility and geopolitical zone. Logistic regression was conducted to identify risk factors for cryptococcal antigenemia. In total, 1,114 patients with AHD were screened. The overall prevalence of asymptomatic cryptococcal antigenemia was 3.9% with wide variation across facilities (range: 0/75 [0%]- 15/122 [12.3%]) and geopolitical zones (range: 0/75 [0%]-19/279 [6.8%]). Prevalence of antigenemia was highest in the South-West (19/279 [6.8%]) and lowest in the North-East (0/75 [0%]). Prevalence was 5.2% (26/512) and 3.2% (18/561) in patients with CD4<100 and CD4 of 101-200, respectively. Of all patients with antigenemia, 50% were on antiretroviral therapy (ART) at the time of having a positive CrAg test. In adjusted analysis, cryptococcal antigenemia was significantly less in patients on ART and patients who had completed any formal education. The survey showed a high overall burden of cryptococcal antigenemia in Nigeria, with variable prevalence across geopolitical regions. We provided valuable evidence for implementing routine CrAg screening of AHD patients in Nigeria which has commenced in selected centres.

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Grants and funding

The funds for this work were provided by CDC Foundation (ROO). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.