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Diagnostic capacity for invasive fungal infections in advanced HIV disease in Africa: a continent-wide survey - 20/04/23

Doi : 10.1016/S1473-3099(22)00656-9 
Sulaiman Lakoh, FWACP a, , Pocha Samuel Kamudumuli, MSc b, , Richard O S Penney, MSci c, Samson M Haumba, DLitt d, Joseph N Jarvis, MRCP e, f, Asha Jama Hassan, MPH g, Ngando Laure E Moudoute, MSc h, Bright K Ocansey, BSc i, j, Santiago Izco, MD k, Stephen Kipkerich, MSc l, Jahit Sacarlal, PhD m, Abimbola T Awopeju, FMCPath n, Nelesh P Govender, ProfFRCPath o, p, q, r, Cleophas If Malaba Munyanji, MPHE s, Kamwiziku Guyguy, MSc t, Emma Orefuwa, MSc c, , David W Denning, ProfFRCPath c, j, ,
a College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone 
b University of Maryland Global Initiative Corporation, Lilongwe, Malawi 
c Global Action For Fungal Infections, Geneva, Switzerland 
d Center for Global Health Practice and Impact, Georgetown University, Mbabane, Eswatini 
e Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK 
f Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana 
g National HIV/AIDS Program, Garowe, Puntland, Somalia 
h Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon 
i Department of Medical Microbiology, University of Ghana Medical School, Accra, Ghana 
j Manchester Fungal Infection Group, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK 
k Office of HIV/AIDS, Tuberculosis and Hepatitis, Ministry of Health and Social Welfare, Malabo, Equatorial Guinea 
l National Public Health Reference Laboratories, Ministry of Health, Nairobi, Kenya 
m Department of Microbiology, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique 
n Department of Medical Microbiology and Parasitology, University of Port Harcourt, Port Harcourt, Nigeria 
o National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa 
p Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa 
q Institute of Infection and Immunity, St George’s University of London, London, UK 
r MRC Centre for Medical Mycology, University of Exeter, Exeter, UK 
s Directorate of Health Laboratories, Ministry of Public Health, Hygiene and Prevention, Kinshasa, DR Congo 
t Department of Microbiology, Kinshasa University Hospital, University of Kinshasa, Kinshasa, DR Congo 

* Correspondence to: Prof David Denning, Manchester Fungal Infection Group, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9NT, UK Manchester Fungal Infection Group University of Manchester Manchester Academic Health Science Centre Manchester M13 9NT UK

Summary

Background

Fungal infections are common causes of death and morbidity in those with advanced HIV infection. Data on access to diagnostic tests in Africa are scarce. We aimed to evaluate the diagnostic capacity for invasive fungal infections in advanced HIV disease in Africa.

Methods

We did a continent-wide survey by collecting data from 48 of 49 target countries across Africa with a population of more than 1 million; for Lesotho, only information on the provision of cryptococcal antigen testing was obtained. This survey covered 99·65% of the African population. We did the survey in six stages: first, questionnaire development, adaptation, and improvement; second, questionnaire completion by in-country respondents; third, questionnaire review and data analysis followed by video conference calls with respondents; fourth, external validation from public or private sources; fifth, country validation by video conference with senior figures in the Ministry of Health; and sixth, through five regional webinars led by the Africa Centres for Disease Control and Prevention with individual country profiles exchanged by email. Data was compiled and visualised using the Quantum Geographic Information System software and Natural Earth vectors to design maps showing access.

Findings

Data were collected between Oct 1, 2020, and Oct 31, 2022 in the 48 target countries. We found that cryptococcal antigen testing is frequently accessible to 358·39 million (25·5%) people in 14 African countries. Over 1031·49 million (73·3%) of 1·4 billion African people have access to a lumbar puncture. India ink microscopy is frequently accessible to 471·03 million (33·5%) people in 23 African countries. About 1041·62 million (74·0%) and 1105·11 million (78·5%) people in Africa do not have access to histoplasmosis and Pneumocystis pneumonia diagnostics in either private or public facilities, respectively. Fungal culture is available in 41 countries covering a population of 1·289 billion (94%) people in Africa. MRI is routinely accessible to 453·59 million (32·2%) people in Africa and occasionally to 390·58 million (27·8%) people. There was a moderate correlation between antiretroviral therapy usage and external expenditure on HIV care (R2=0·42) but almost none between external expenditure and AIDS death rate (R2=0·18), when analysed for 40 African countries.

Interpretation

This survey highlights the enormous challenges in the diagnosis of HIV-associated Pneumocystis pneumonia, cryptococcal disease, histoplasmosis, and other fungal infections in Africa. Urgent political and global health leadership could improve the diagnosis of fungal infections in Africa, reducing avoidable deaths.

Funding

Global Action For Fungal Infections.

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© 2023  Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Publié par Elsevier Masson SAS. Tous droits réservés.
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Vol 23 - N° 5

P. 598-608 - mai 2023 Retour au numéro
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