BMJ Open (Jun 2023)

Implementation of point-of-care testing and prevalence of cryptococcal antigenaemia among patients with advanced HIV disease in Mumbai, India

  • Amit Harshana,
  • Raman Mahajan,
  • Reshu Agarwal,
  • Shrikala Acharya,
  • Amol Palkar,
  • Ramesh Reddy Allam,
  • Vijay Kumar Karanjkar,
  • Dhirubhai Rathod,
  • Prashant Deshpande,
  • Shashikant Todmal,
  • Sagar Koli,
  • Sachin Dhande,
  • Jayesh Dale,
  • Vijay V Yeldandi,
  • Sunita Upadhyaya,
  • Melissa Nyendak

DOI
https://doi.org/10.1136/bmjopen-2022-070500
Journal volume & issue
Vol. 13, no. 6

Abstract

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Objectives To describe the implementation of screening for cryptococcal antigenaemia by point-of-care (POC) serum cryptococcal antigen (CrAg) lateral flow assay, measure the prevalence and factors associated with serum cryptococcal antigenaemia in the routine programmatic setting.Design Cross-sectional study.Setting Seventeen publicly funded antiretroviral therapy (ART) centres in Mumbai, India.Participants Serum CrAg screening was offered to all adolescents (>10 years of age) and adults with advanced HIV disease (AHD) (CD4 <200 cells/mm3 or with WHO clinical stage III/IV) regardless of symptoms of cryptococcal meningitis.Primary and secondary outcome measures The primary outcome was to describe the implementation of serum CrAg screening and secondary outcome was to measure the prevalence of serum cryptococcal antigenaemia and its risk factors.Results A total of 2715 patients with AHD were tested for serum CrAg by POC assay. Of these, 25 (0.9%) had a CrAg positive result. Among CrAg-positive patients, only one had symptoms. Serum CrAg positivity was 3.6% (6/169) and 1.6% (6/520) among those presenting with CD4 <100 cells/mm3 in the treatment naïve and treatment experienced group, respectively. On multivariable analysis, CD4 count <100 cells/mm3 (OR: 2.3, 95% CI 1.01 to 5.3; p=0.05) and people living with HIV who were treatment naïve (OR: 2.5, 95% CI 1.04 to 6.0; p=0.04) were significantly associated with a positive serum CrAg result. Lumbar puncture was obtained in 20/25 patients within 4 days (range: 1–4 days) of positive serum CrAg result and one person was confirmed to have meningitis. All serum CrAg-positive patients who had a negative cerebrospinal fluid CrAg were offered pre-emptive therapy.Conclusions Implementation of a POC CrAg assay was possible with existing ART centre staff. Initiation of pre-emptive therapy and management of cryptococcal antigenaemia are operationally feasible at ART centres. The Indian National AIDS Control Programme may consider reflexive CrAg screening of all AHD patients with CD4 <100 cells/mm3.