Increasing access to diagnostic testing in Africa for patients with HIV-associated cryptococcal disease, histoplasmosis, Pneumocystis pneumonia, and other fungal infections is needed to improve patient care and reduce avoidable mortality. These study findings were published in The Lancet Infectious Diseases.
Between October 2020 and 2022, researchers surveyed clinicians affiliated with 72 health facilities located across 48 African countries to assess the access and frequency of diagnostic testing for fungal infections in patients with HIV infection. The researchers targeted countries with populations of more than 1 million, and a snowball sampling technique was used for survey distribution.
Among the 72 survey respondents, nearly half (45.8%) reported country-wide data, and data from 14 countries was reported by more than 1 respondent.
For evaluating cryptococcal disease, India ink staining of cultured blood or cerebrospinal fluid samples is commonly used. The researchers found cryptococcal antigen testing was accessible across 14 African countries comprising 358.39 million individuals. These countries tended to be located in Southern and Eastern Africa. No access was reported in 22 countries (n=613.10 million).
Rapid urinary antigen testing for histoplasmosis was found to be commonly used in Niger and Burundi (public setting), as well as in Mozambique (private setting). Clinicians from 40 countries comprising a population of 1041.62 million individuals reported no access to this testing method.
For Pneumocystis jirovecii, polymerase chain reaction (PCR) testing or specialized microscopy with respiratory samples for pathogen visualization is commonly used. As with histoplasmosis testing, access to Pneumocystis jirovecii diagnostic testing was limited, with clinicians reporting 1105.11 million individuals with no access in the public or private sectors.
Access to fungal testing was found to be adequate in 41 countries. For 22 of these countries, fungal testing was frequently performed in the public health setting. A total of 8 countries comprising 79.68 million individuals were found to lack facilities for fungal culture analysis.
Access to magnetic resonance imaging (MRI) as an ancillary diagnostic tool for cerebral toxoplasmosis, cytomegalovirus encephalitis, cryptococcoma, lymphoma, tuberculoma, and progressive multifocal leukoencephalopathy was reported to be readily accessible for 453.59 million (32.2%) individuals across the African population. However, access to this testing was found to be occasionally accessible for 390.58 million (27.8%) individuals and rarely accessible for 337.33 million (24.0%) individuals. There were 12 countries with no MRI facilities in the public sector and 15 countries with no MRI facilities in the private sector.
Of note, a moderate correlation between antiretroviral therapy use rates and funding for HIV care (R² =.42) was noted in 40 countries, though correlations between external funding and AIDS-related mortality limited (R² =.18).
Limitations of this study include the lack of data collected from countries with populations of less than 1 million and potential bias introduced by the snowball sampling technique.
According to the researchers, “We need to advocate to the political and global health leadership and mobilize resources to improve and sustain the capacity of African countries to detect fungal infections.”
Lakoh S, Kamudumuli PS, Penney ROS, et al. Diagnostic capacity for invasive fungal infections in advanced HIV disease in Africa: a continent-wide survey. Lancet Infect Dis. Published online December 21, 2022. doi:10.1016/S1473-3099(22)00656-9