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. 2022 Mar 5;22(1):224.
doi: 10.1186/s12879-022-07224-6.

Implementation of tuberculosis and cryptococcal meningitis rapid diagnostic tests amongst patients with advanced HIV at Kamuzu Central Hospital, Malawi, 2016-2017

Cecilia Kanyama  1 , Maganizo B Chagomerana  2 , Chimwemwe Chawinga  2 , Jonathan Ngoma  3 , Idah Shumba  2 , Wiza Kumwenda  2 , Billio Armando  4 , Tapiwa Kumwenda  5 , Emily Kumwenda  2 , Mina C Hosseinipour  2
Affiliations

Implementation of tuberculosis and cryptococcal meningitis rapid diagnostic tests amongst patients with advanced HIV at Kamuzu Central Hospital, Malawi, 2016-2017

Cecilia Kanyama et al. BMC Infect Dis. .

Abstract

Background: Cryptococcal meningitis (CM) and tuberculosis (TB) remain leading causes of hospitalization and death amongst people living with HIV, particularly those with advanced HIV disease. In hospitalized patients, prompt diagnosis of these diseases may improve patient outcomes. The advanced HIV rapid diagnostic tests such as determine TB urine lipoarabinomannan lateral flow assay (urine LAM), urine X-pert MTB/RIF assay (urine X-pert), and serum/blood cryptococcal antigen test (serum CrAg) are recommended but frequently not available in many resource-limited settings. We describe our experience providing these tests in a routine hospital setting.

Method: From 1 August 2016 to 31 January 2017, a prospective cohort study to diagnose TB and Cryptococcal meningitis using point of care tests was conducted in the medical wards at Kamuzu Central Hospital, in Lilongwe, Malawi. The tests offered were PIMA CD4 cell count, serum CrAg, urine LAM, and urine X-pert. The testing was integrated into an existing HIV/TB treatment room on the wards and performed close to admission time. Patients were followed until discharge or death in the ward.

Results: We included 438 HIV-positive patients; 76% had a previously known HIV diagnosis (87% already on ART). We measured CD4 count in 365/438 (83%), serum CrAg in 301/438 (69%), urine LAM in 363/438 (83%), and urine X-pert in 292/438 (67%). The median CD4 count was 144 cells/ml (IQR 46-307). Serum CrAg positivity rate was 23 /301 (8%) and CM was confirmed by CSF Crag in 13/23 (56%). The majority of CM patients 9/13 (69%) started antifungal therapy within two days of diagnosis. Urine LAM and urine X-pert positivity rates were 81/363(22%) and (14/292 (5%) respectively. The positivity rate of urine LAM was higher in patients with low CD4 cell counts (< 100 cells/ml) and low BMI (< 18.5). Most patients with positive urine LAM started TB treatment on the same day. Despite the early diagnosis and treatment of TB and CM, the inpatient mortality was high; 30% and 25% respectively.

Conclusion: Although advanced HIV rapid diagnostic tests are recommended, one key challenge in implementation is the limited trained personnel administering the tests. Despite the effective use of the point of care tests in the clinical care of hospitalized TB and CM patients, mortality among these patients remained unacceptably high. Henceforth we need to train other cadres apart from nurses, clinicians, and laboratory technicians to conduct the tests. There is an urgent need to identify and modify other risks of death from TB and CM.

Trial registration: Malawi National Health Science Research committee: Protocol # 1144. Registered 2 July 2014 and University Of North Carolina IRB #: UNCPM 21412, approved 13th October 2014.

Keywords: Advanced HIV disease; Cryptococcal disease; HIV; Malawi; Rapid diagnostic test; Tuberculosis.

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Conflict of interest statement

The authors declare that they have no competing interests.

References

    1. Reniers G, Slaymaker E, Nakiyingi-Miiro J, Nyamukapa C, Crampin AC, Herbst K, et al. Mortality trends in the era of antiretroviral therapy: evidence from the Network for Analysing Longitudinal Population based HIV/AIDS data on Africa (ALPHA) AIDS. 2014;28(Suppl 4):S533–542. doi: 10.1097/QAD.0000000000000496. - DOI - PMC - PubMed
    1. Palella FJ, Baker RK, Moorman AC, Chmiel JS, Wood KC, Brooks JT, et al. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. J Acquir Immune Defic Syndr. 2006;43(1):27–34. doi: 10.1097/01.qai.0000233310.90484.16. - DOI - PubMed
    1. Matoga MM, Rosenberg NE, Stanley CC, LaCourse S, Munthali CK, Nsona DP, et al. Inpatient mortality rates during an era of increased access to HIV testing and ART: a prospective observational study in Lilongwe, Malawi. PLoS ONE. 2018;13(2):e0191944. doi: 10.1371/journal.pone.0191944. - DOI - PMC - PubMed
    1. Wajanga BM, Webster LE, Peck RN, Downs JA, Mate K, Smart LR, et al. Inpatient mortality of HIV-infected adults in sub-Saharan Africa and possible interventions: a mixed methods review. BMC Health Serv Res. 2014;3(14):627. doi: 10.1186/s12913-014-0627-9. - DOI - PMC - PubMed
    1. Carmona S, Bor J, Nattey C, Maughan-Brown B, Maskew M, Fox MP, et al. Persistent high burden of advanced HIV disease among patients seeking care in South Africa’s National HIV Program: data from a nationwide laboratory cohort. Clin Infect Dis. 2018;66(suppl_2):S111–S117. doi: 10.1093/cid/ciy045. - DOI - PMC - PubMed

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