title: Cryptococcal Antigenemia in Nigerian Patients With Advanced Human Immunodeficiency Virus: Influence of Antiretroviral Therapy Adherence.
abstract: Background.  Cryptococcal meningitis has a high mortality in human immunodeficiency virus (HIV)-infected persons in Africa. This is preventable with early screening and preemptive therapy. We evaluated the prevalence of cryptococcal disease by antigen testing, possible associated factors, and outcomes in HIV-infected patients being managed in a tertiary hospital in Lagos, Nigeria. Methods.  Sera were collected from 214 consenting HIV-infected participants with CD4(+) counts <250 cells/mm(3), irrespective of their antiretroviral therapy (ART) status, between November 2014 and May 2015. A cryptococcal antigen (CrAg) lateral flow assay was used for testing. Pertinent clinical data were obtained from patients and their case notes. Results.  Of the 214 participants, females (124; 57.9%) outnumbered males. Mean age was 41.3 ± 9.4 (standard deviation) years. The majority (204; 95.3%) were ART experienced. The median CD4(+) cell count was 160 cells/mm(3) (interquartile range, 90-210). The overall seroprevalence of cryptococcal antigenemia was 8.9% (19 of 214); 6 of 61 (9.8%) in those with CD4(+) cell counts <100 cells/mm(3), 4 of 80 (5.0%) in the 100-200 group, and 9 of 73 (12.3%) in 200-250 cells/mm(3) group. Among ART-naive patients, 1 of 10 (10%) was CrAg positive. Twenty-seven of 214 (12.6%) had associated oral thrush. Potential baseline meningitis symptoms (3 of 214 [1.4%] experienced neck pain or stiffness and 21 of 214 [9.8%] experienced headache) were common in the study group, but the result was not statistically significant in relation to CrAg positivity. Two of 19 (10.5%) CrAg-positive patients died, 10 of 19 (52.6%) were lost to follow up, and 7 of 19 (36.8%) were alive. Empirical fluconazole was routinely given to those with low CD4 counts <100 cells/mm(3), which was unrelated to CrAg positivity (P = .018). Conclusions.  We report a prevalence of 8.9% cryptococcal antigenemia in a setting where first-line antifungals are not readily available. We recommend CrAg screening for HIV-infected patients, even for patients on ART.
authors.affiliation: The University of Manchester, United Kingdom; College of Medicine of University of Lagos.
authors.forename: Rita O
authors.initials: RO
authors.lastname: Oladele
authors.affiliation: US President's Emergency Plan for AIDS Relief Clinic , Lagos University Teaching Hospital.
authors.forename: Alani S
authors.initials: AS
authors.lastname: Akanmu
authors.affiliation: AIDS Prevention Initiative in Nigeria, Central Laboratory , College of Medicine of University of Lagos , Nigeria.
authors.forename: Augustina O
authors.initials: AO
authors.lastname: Nwosu
authors.affiliation: College of Medicine of University of Lagos.
authors.forename: Folasade T
authors.initials: FT
authors.lastname: Ogunsola
authors.affiliation: The University of Manchester, United Kingdom; National Aspergillosis Centre and Mycology Reference Centre Manchester, University Hospital of South Manchester and Manchester Academic Health Science Centre, United Kingdom.
authors.forename: Malcolm D
authors.initials: MD
authors.lastname: Richardson
authors.affiliation: The University of Manchester, United Kingdom; National Aspergillosis Centre and Mycology Reference Centre Manchester, University Hospital of South Manchester and Manchester Academic Health Science Centre, United Kingdom.
authors.forename: David W
authors.initials: DW
authors.lastname: Denning
keywords: HIV infection; antiretroviral therapy; cryptococcal antigenemia; fluconazole; sub-Saharan Africa