Asymptomatic cryptococcal antigenemia is associated with mortality among HIV‐positive patients in Indonesia

Abstract

IntroductionPrevious studies, mostly from Africa, have shown that serum cryptococcal antigenemia may precede the development of cryptococcal meningitis and early death among patients with advanced HIV infection. We examined cryptococcal antigenemia as a risk factor for HIV-associated mortality in Indonesia, which is experiencing a rapidly growing HIV epidemic.MethodsWe included ART-naïve HIV patients with a CD4 cell count below 100 cells/μL and no signs of meningitis in an outpatient HIV clinic in Bandung, West Java, Indonesia. Baseline clinical data and follow-up were retrieved from a prospective database, and cryptococcal antigen was measured in stored serum samples using a semiquantitative lateral flow assay. Cox regression analysis was used to identify factors related to mortality.ResultsAmong 810 patients (median CD4 cell count 22), 58 (7.1%) had a positive cryptococcal antigen test with a median titre of 1:80 (range: 1:1 to 1:2560). Cryptococcal antigenemia at baseline was strongly associated with the development of cryptococcal meningitis and early death and loss to follow-up. After one year, both death (22.4% vs. 11.6%; p=0.016; adjusted HR 2.19; 95% CI 1.78–4.06) and the combined endpoint of death or loss to follow-up (67.2% vs. 40.4%; p<0.001; adjusted HR 1.57; 95% CI 1.12–2.20) were significantly higher among patients with a positive cryptococcal antigen test.ConclusionsCryptococcal antigenemia is common and clinically relevant among patients with advanced HIV in this setting. Routine screening for cryptococcal antigen followed by lumbar puncture and pre-emptive antifungal treatment for those who are positive may help in reducing early mortality.

Utility of urine and serum lateral flow assays to determine the prevalence and predictors of cryptococcal antigenemia in HIV‐positive outpatients beginning antiretroviral therapy in Mwanza, Tanzania

“…The prevalence of cryptococcal antigenemia in this study (7.1%) is higher than rates reported from rural Uganda (5.8%) [12] and northeastern Tanzania (5%) [19] but similar to another study in South Africa (7%) [22] and also to a recently published study in Indonesia (7.1%) [14]. Other studies have shown that the diagnostic methods, host factors including prior receipt of ART, and seasonal changes may influence the prevalence in different settings [2, 12, 19, 23–25].…”

Cryptococcal Antigenaemia among Treatment-Na&#239;ve Adult HIV-Infected Nigerian Patients

“…More female patients 248 (57.4%) than males 184 (42.6%) were enrolled for our study and all the CrAg positive subjects were female 7 (100%). This is contrary to previous reports from studies where more males were enrolled and also found CrAg positive [15] [23]. Most of the patients in our study were in age group 29 -39 years and this observation is similar to findings in a previous research with 24 -40 years [27].…”

“…Our observed overall low cryptococcal antigenaemia of 1.6% among treatment naïve HIV positive patients is comparable with previous reports from Shika in Nigeria 2.2 % [17], Tanzania 3% [18] and USA 2.9% [19]. However our overall prevalence value in this study is lower than some reports from Nnewi 13.1% [20] South east, and Benin12.7% [12] South south part of Nigeria as well as Kenya 11% [21], Uganda 5.7% [22], Indonesia 7.1% [23] and Thailand 9.2% [24]. The observed differences in prevalence rates of cryptoccocal antigen positivity among HIV infected persons in the various studies cited may be explained by differences in sample sizes as well as varying sensitivities and specificities with differing methodologies of used kits.…”

A Cross-Sectional Study of Cryptococcal Antigenemia in Anti-Retroviral Naive Hiv Infected Patients

“…18 A study from Indonesia documented a weak correlation between CD4 cell counts and the titre of cryptococcal antigen. 19 Whereas in the present study there was no correlation; however, the titre of cryptococcal antigen could not be estimated due to limited resources.…”