Implementation of a rapid diagnostic assay package for Cryptococcosis, Histoplasmosis and Tuberculosis in People Living with HIV in Paraguay

Implementation of a rapid diagnostic assay package for Cryptococcosis, Histoplasmosis and Tuberculosis in People Living with HIV in Paraguay | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementation of a rapid diagnostic assay package for Cryptococcosis, Histoplasmosis and Tuberculosis in People Living with HIV in Paraguay Gloria Aguilar, Gladys Lopez, Omar Sued, Narda Medina, Diego H Caceres, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3938634/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Opportunistic infections (OIs) are common causes of mortality among people living with HIV (PLHIV). We determined prevalence and 30-day mortality due to histoplasmosis, cryptococcosis, and TB in PLHIV with advanced HIV disease (AHD). Methods PLHIV 18 years and older, not receiving ART with advanced HIV were enrolled and followed for 30 days. Detection of Histoplasma Ag (HisAg) in urine was done by enzyme immunoassay (EIA), Cryptococcus antigen (CrAg) was detected in serum and cerebrospinal fluid (CSF) specimens by lateral flow assay (LFA), and lipoarabinomannan (LAM) detection in urine was by LFA (TB LAM) and in sputum by GeneXpert for diagnosis of Mycobacterium infections. Results From August 2021 to June 2022, 491 PLHIV were enrolled; 482 (98%) had a CD4 result, and 381 patients (79%) were classified with AHD according to CD4 cell count (< 200 CD4/mm 3 ). Frequency of an OI was 38% (n = 145/381). Antigen test positivity rate was 16% (72/467) for TB-LAM, 9% (43/464) for HisAg, and 11% (51/484) for CrAg. Twenty-one of 34 (62%) patients receiving CSF CrAg tests were positive, confirming meningitis. Significant differences in 30-day mortality were observed in patients with an OI (16%) vs no OI (7%) ( p = 0.002). Mortality was highest in patients with histoplasmosis (25%), co-infection (22%), cryptococcosis (18% overall; 19% for cryptococcal meningitis), and TB (10%). Conclusions TB and fungal (OIs), including co-infection, were common in PLHIV in Paraguay and had high associated mortality. Laboratories and health facilities need access to CD4 testing and rapid diagnostic assays. opportunistic infections HIV diagnostic Paraguay Figures Figure 1 Figure 2 Introduction Expanded HIV testing and rapid initiation of antiretroviral therapy (ART) can reduce advanced HIV disease (AHD) which is defined by the World Health Organization (WHO) as those with a CD4 cells count below 200 cells/mm 3 or WHO stage 3 or 4 illness in adults and adolescents [ 1 ]. Routine screening for opportunistic infections amongst patients with AHD can increase early detection of individuals who need urgent management to reduce deaths [ 1 ]. In Paraguay in 2020, an estimated 16, 233 people were living with HIV (PLHIV). Of these, 89% had been diagnosed, 70% were on ART and 49% were virally suppressed with an undetectable viral load. In 2021, 36% of PLHIV with a recent diagnosis presented with advanced HIV disease (AHD) [ 2 ]. PLHIV with AHD are at higher risk of opportunistic infections (OIs), including cryptococcosis, histoplasmosis, and tuberculosis (TB)[ 3 – 6 ]. The main challenges in identifying these infections are the non-specificity of clinical signs and symptoms, a low clinical suspicion for fungal infections, and limited access to rapid and accurate diagnostic tests [ 4 , 7 – 9 ]. Conventional laboratory methods for the diagnosis of these OIs, such as culture or histopathology, present several limitations, including the need for complex laboratory infrastructure, trained professionals, and long turnaround time for results, particularly for diagnosis of histoplasmosis and tuberculosis[ 9 – 11 ]. WHO recommends the use of antigen-based tests for the rapid diagnosis of cryptococcosis, histoplasmosis, and TB among PLHIV with AHD[ 3 – 6 ]. The use of LAM is recommended for all individuals with signs and symptoms of tuberculosis (TB), as well as for admitted asymptomatic patients with < 200 cell/ mm 3 or outpatients with < 100 cell4/ mm 3 . WHO also recommends the detection of Cryptococcus antigen (CrAg) and Histoplasma antigen (HisAg) in individuals with AHD. In Paraguay, national screening of TB in PLHIV has increased from 33% in 2010 to 86% in 2018. In 2020, 8% of all HIV cases registered had a diagnosis of TB[ 12 ]. Cryptococcosis and histoplasmosis are endemic mycoses in the region, but the burden of these diseases in Paraguay is unknown. Previous reports have shown that implementing rapid diagnostics assays (RDA) for OIs can positively impact patient care[ 9 , 13 , 14 ]. The use of these assays has been shown to increase the number of cases diagnosed and reduce mortality[ 13 , 15 – 17 ] Currently, there are commercially available RDAs, which have facilitated the implementation of rapid diagnostics for cryptococcosis, histoplasmosis, and TB. These assays, including immunoassays (EIA) and lateral flow assays (LFA) support diagnosis of disease through detection of circulating antigen (Ag)Commercial assays are also available for the detection of DNA, including the Biofire® FilmArray® for the diagnosis of cryptococcosis and TB and the Cepheid’s, GeneXpert® Systems for the diagnosis of TB. This report describes the results from implementation of a package of diagnostic assays for the detection of cryptococcosis, histoplasmosis, and TB in PLHIV at the Instituto de Medicina Tropical (IMT) in Asuncion, Paraguay. This health facility provides care for 72% of the HIV patients enrolled in care at the national level Paraguay. We also describe the prevalence of cryptococcosis, histoplasmosis, and TB, and analyze the 30-day survival of patients with these infections and for all enrolled patients. Methods Study design and participants PLHIV were prospectively enrolled at the IMT in Asuncion, Paraguay from August 2021 to July 2022. Patients were recruited from the emergency room, inpatient ward, and the outpatient HIV clinic. We included adults over the age of 18 years who consented to participate. Two groups were defined, the first included asymptomatic PLHIV with a CD4 count of less than 350 cells/mm 3 newly diagnosed with HIV infection or re-engaged in care after being without ART for more than 90 days (Group A). The second group included symptomatic PLHIV regardless of ART status or CD4 count (Group B). Symptomatic PLHIV included those patients with any symptom suggestive of systemic infections within the last 14 days (fever, cough, expectoration, weight loss, night sweats, altered mental status, headache, focal neurological signs, lymphadenopathies, or extensive mucosal or skin lesions). Individuals were excluded if less than 18 years old, were HIV uninfected or if they had received active treatment during the last 2 weeks for TB and/or systemic fungal diseases. Laboratory procedures and case definitions For asymptomatic individuals, a CD4 count was performed if the patient did not have a previous CD4 count in the last three months. All patients with respiratory symptoms and sputum production were asked to provide a sputum specimen for GeneXpert MTB/RIF per Paraguay National TB Program guidelines [ 18 ]. Microscopic analysis, culture, and molecular testing by GeneXpert MTB/RIF were done on respiratory specimens. Complementary analysis such as the Film Array® (Biomérieux, Marcy-l’Étoile, France) were performed at the attending clinician’s request and in those patients suspected of extra pulmonary infections caused by mycobacteria or others OIs. The clinical management and treatment for any diagnosed OIs were provided by the attending clinician per local practice and national guidelines. Laboratory assays for cryptococcosis, histoplasmosis, and TB were done following the manufacturer’s instructions. Cryptococcus Ag (CrAg) was detected in sera using a commercial LFA kit (CrAg® LFA, IMMY, Norman, OK, US). In patients with positive CrAg, the laboratory requested cerebrospinal fluid (CSF) specimens for CrAg LFA testing to rule out Cryptococcus meningitis (CM). India link and CSF fungal culture were also performed on CSF when available. Detection of Histoplasma urinary antigen (HGM) was performed using the Clarus Histoplasma GM EIA (IMMY, Norman, OK, US), specimens were tested using the standard curve method. A positive result was considered if the specimen presented a concentration of HGM higher or equal to 0.2 ng/ml. For TB, lipoarabinomannan Ag (LAM) was tested in urine (DETERMINE TB LAM Ag, Abbott, Maine, USA). LAM was defined as positive using the grade one cutoff on the manufacturer’s post-2014 reference card. Cases were defined as follows: (i) Cryptococcosis : a positive CrAg in sera. (ii) Cryptococcus meningitis: a positive CrAg, Indian ink, or culture in CSF. (iii) Histoplasmosis : a positive HGM test or other laboratory evidence of histoplasmosis such as positive histopathology or culture and (iv) Bacteriologically confirmed TB: culture-positive, or a WHO-recommended rapid molecular test such as Xpert MTB/RIF, or a positive TB-LAM test. Protocol training, data collection, and monitoring Prior to patient enrollment, the study staff were trained in appropriate clinical practices, specimen collection, and performing laboratory tests to assure the standard quality of the laboratory procedures. The local study coordinator undertook training sessions with the hospital staff to ensure protocol compliance. Bi-monthly meetings were held to follow protocol progress. A standard case report form was designed using EPI-INFO for data collection of demographic and clinical characteristics, test results and 30-days outcome. Patients unable to be contacted after at least three phone calls or domiciliary visits were considered lost-to-follow-up. Cross-checks with the national HIV database, the national TB database, and the death registry, were done regularly by the National AIDS Program to evaluate accuracy of study data. Ethical approval The IMT ethical committee, and the Pan American Health Organization Ethical Research Committee (PAHOERC) approved the protocol under register PAHOERC.0347.01. Signed written consent was sought from each patient before performing any procedure. No personal identifiable information was collected in the database used for the analysis. Data was compiled by trained professionals and stored in a secure database. CDC staff were determined to be non-engaged in the pilot screening activities and therefore the pilot was determined to be exempt from Centers for Disease Control and Prevention (CDC) IRB review. Statistical analysis Statistical Package for the Social Sciences, version 25.0 (SPSS Inc., Chicago, IL, USA), was used for analysis. Categorical variables were summarized as counts and percentages. Continuous variables were summarized using medians and their corresponding interquartile ranges (IQRs). We assessed the association between baseline characteristics and the presence of opportunistic infections at admission using chi-square, fisher’s exact test (categorical variables) and Wilcoxon rank-sum test (continuous variables). A p value <0.05 was considered statistically significant. Results Study population and opportunistic infections Between August 2021 to June 2022, a total of 491 PLHIV were enrolled for screening; 365 (74%) were male, 278 (57%) were aged less than 40 years and 58% resided in urban areas ( Table 1 ). At the time of screening, 217 (44%) were newly diagnosed with HIV infection. Three hundred and eighty-one patients (78%) were detected with AHD based on CD4 cell count (<200 cells/mm3) only. Out of the 491 patients enrolled, 162 (33%) were diagnosed with at least one of the OIs being screened for. Of these 92 (19%) had a diagnosis of TB, 52 (11%) had cryptococcosis (51 diagnosed by serum LFA-CrAg and one through culture) and 43 (9%) had histoplasmosis. Among the 162 patients with a diagnosed OI, 23 patients (14%) had multiple OIs (histoplasmosis and TB in 16 patients (70%); cryptococcosis and TB in 4 patients (17%); cryptococcosis and histoplasmosis in one (4%); triple infection in two patients (9%). Comparing patients with (n=162) and without any of these three OIs (n=329), the median CD4 cell count was significantly lower in patients with OIs than those without OIs (median CD4 cell count 59 cells/mm 3 vs. 106 cells/mm 3 respectively, p < 0.0001). In asymptomatic patients with CD4 <350 cells/mm 3 (group A, n=68), seven patients (10%) were diagnosed with an OI. Of these, one had cryptococcosis without meningitis,two had histoplasmosis, three had TB and one had TB and histoplasmosis co-infection. In contrast, in symptomatic patients (group B, n=423), 155 (37%) were diagnosed with an OI ( p < 0.0001) (Table 1) . Among patients with CD4 <200mm 3 , the frequency of the targeted OIs was 38% (n=145). Among patients with CD4 counts between 200 and 350/mm 3 , the frequency of OIs was 20% (P = 0.0035 ) ( Figure 1 ). All targeted OIs were found in patients with CD4 ≤ 350/mm 3 . The frequency of OIs increased as the count of CD4 cells decreased ( Table 2 ). Two cases of OI (one histoplasmosis and one tuberculosis) occurred in patients without a CD4 cell count. Opportunistic infection diagnosis For histoplasmosis screening, 464 of 491 (95%) patients were tested for Histoplasma antigen detection in urine ( Table 3 ). Of these, 43 (9%) tested positive. For those not tested, lack of referral of urine to the laboratory for testing was given as the main cause. For Cryptococcus screening, 484 of 491 (99%) patients were tested using CrAg LFA in sera, 51 (10%) were positive. One patient, for whom serum CrAg testing was not conducted, was diagnosed with cryptococcal meningitis through culture and Indian ink examination of cerebrospinal fluid (CSF). Among the 51 patients with positive CrAg in sera, testing of cerebrospinal samples (CSF) was done in 34 patients (67%). Twenty-one of the 34 (62%) CSF samples tested positive for CrAg, confirming meningitis. Detection of CrAg in CSF samples by the LFA-CrAg assay yielded a higher positivity rate than did CSF culture (62% vs. 50%). Of all enrolled patients, 467 (95%) were screened with TB-LAM, 204 (42%) with GeneXpert, and 102 (21%) were tested by culture. Of these, 72 (15%), 35 (17%), and 22 (22%) were positive, respectively. The highest positivity rate was observed in patients receiving both TB-LAM and GeneXpert testing ( Table 3 ). In this group of 197 patients, a total of 62 TB cases were diagnosed. Among them, 29 (47%) were diagnosed solely through TB-LAM, 15 (24%) through GeneXpert alone, and 29% (n=18, 29%) through a combination of both tests. Treatment and outcomes Of the 92 cases diagnosed with tuberculosis, 83 (90%) received antituberculosis treatment. Of the 43 histoplasmosis cases, 36 (84%) initiated antifungal treatment, (21 with amphotericin B deoxycholate, 12 with itraconazole, three with fluconazole). For cryptococcosis (n=52), all patients initiated antifungal treatment for either cryptococcal meningitis or non-meningeal cryptococcosis based on confirmation of cryptococcal meningitis and clinical judgment; (31 with amphotericin B and fluconazole, 21 with fluconazole for pre-emptive treatment). Of all enrolled patients, 486 were followed prospectively for 30-days. Mortality in this period was 10% (49 patients), including 26 (53%) patients with an OI diagnosed in this study (eight cryptococcosis, seven tuberculosis, six histoplasmosis, and five multiple opportunistic infections). Patients with OIs had significantly higher mortality than patients without opportunistic infections (16% vs. 7%; p = 0.002). The highest mortality rate (25%) was observed in patients with histoplasmosis, followed by multiple opportunistic infections (22%), cryptococcosis (18%), and tuberculosis (10%) (p = 0.004). For those with confirmed cryptococcal meningitis, the mortality rate was 19%. Discussion In this prospective study, one out of three PLHIV with advanced HIV or new HIV diagnosis had cryptococcosis, histoplasmosis or TB. Routine screening using rapid diagnostic assays provided early detection of these OIs. Here, we found that most PLHIV enrolled had AHD (79%). As shown in Figure 2, the OIs evaluated in this study were more frequent in patients with very low CD4 cell counts (< 50 cells/mm 3 ); all detected cases of the targeted OIs were in patients with ≤ 350 cells/mm 3 . The WHO recommends screening for CrAg in patients with <200 cells/mm 3 and for TB LAM <100 cells/mm 3 among outpatients as well as any symptomatic inpatients[6,19]. Our findings align with results from a recent analysis in Guatemala, in which 95% of OIs were diagnosed using a 350 CD4 threshold in a screening program for newly HIV diagnosed patients [13]. When considering an appropriate CD4 cell count threshold for implementing this diagnostic package for opportunistic infections, program planners must balance the burden of AHD and of the targeted OIs, while also considering the cost implications for HIV programs. A study in 2023 by Rajasingham and colleges assessed the cost-effectiveness of integrating Histoplasma antigen testing in patients with AHD at a large scale,and estimated that it is cost-effective [20]. However, the public health impact, and cost of an approach that targets individuals with CD4 counts between 200 and 350 for routine screening with these rapid OI diagnostics requires additional evaluation and should be weighed by program planners in the context of the local HIV and OI burden and resource availability. [13] Data on the burden of these diseases in Paraguay is historically scarce. The overall frequency of CrAg in serum samples in the present study (11%) is similar to that reported in Brazil with a frequency of 11.2% in patients with AHD[21]. Several studies have reported the diagnostic value of the LFA in detecting cryptococcosis, including in asymptomatic patients. Cryptococcus antigenemia is a well described risk factor for developing cryptococcal meningitis, and requires antifungal therapy tailored to whether concurrent CM is confirmed or suspected [14,22]. Here, we found that 62% of the serum CrAg positive cases had CM. Within 30 days of follow up 19% of serum CrAg positive patients had died, a result which emphasizes the need for routine and rapid access to appropriate antifungal treatment for patients with cryptococcosis Histoplasmosis imposes a significant burden in this region, with prevalences of 10% and higher reported among individuals with advanced HIV disease in the region[23,24]. Co-occurrence with TB and other opportunistic infections is common, highlighting the need for improved capacity to detect histoplasmosis as part of the routine workup of individuals with advanced HIV disease in this region[25,26]. Our screening strategy classified patients based on the presence or absence of general symptoms, which is a key clinical indicator. At the time of screening, 5% of the asymptomatic patients with AHD received a diagnosis of an OI. In the absence of this strategy, these cases may have progressed to severe disease, requiring more complex care with a higher likelihood of negative outcomes. Using Histoplasma Ag testing, a total of 43 people with histoplasmosis were detected. It is important to highlight that histoplasmosis was the only OI in 24 patients, in the remaining 19 (44% patients), coinfection with histoplasmosis and other OIs occurred, TB coinfection being the most common (18 of 19 co-infected). This coinfection is commonly reported in Latin America. Several case series and cohorts of PLHIV report the co-occurrence of histoplasmosis-TB ranging from 2% to 38% [11]. A recent review of studies in Latin America which used Histoplasma Ag testing showed that use of the test had a positive impact on case detection, increased diagnostic yield, and in some reports doubled the number of diagnosed cases [27,28]. Additionally, a reduction in mortality of patients diagnosed with histoplasmosis was reported when using rapid antigen testing [29]. Our implementation study used urine antigen testing to detect histoplasmosis, and a small number of cases could have been missed due to challenges in collection of urine, or due to problems in the transport of urine specimens to the laboratory. The package of diagnosis provided here could be further improved by the incorporation of point of care LFA for histoplasmosis. There is limited data on how to optimally integrate different assays for TB in the region. In this study, when Xpert® MTB/RIF Ultra - Cepheid and TB-LAM tests were both used, the urine TB-LAM test had an incremental yield of 47%. The combination of both assays identified a higher proportion of tuberculosis cases (62 of 197 patients tested). These findings are consistent with a multicenter study in which the combination of TB-LAM and GeneXpert tests had the highest sensitivity[30]. Thus, our data supports the importance of incorporating both tests into routine health care for PLHIV. Additional studies including qualitative methods are needed to identify the challenges and gaps in integrating these tests in the package of care for PLHIV. Overall, the 30-day mortality in this cohort was high and, as expected, was higher among patients with opportunistic infections. Patients with histoplasmosis and those with multiple OIs had the highest mortality rates of 25% and 22% respectively. Most of these patients were highly immunocompromised, with the median CD4 counts the lowest among patients with multiple OIs (median 42 cells/mm 3 ). The most frequent common co-infection was histoplasmosis and TB (70%). Treatment of histoplasmosis/TB coinfection is challenging due to the pharmacokinetic drug-drug interactions of itraconazole and some common TB medicines [8]. Concerning histoplasmosis, clinical manifestations are nonspecific and often resemble those produced by other common infections such as TB. In the absence of a strategy to accurately detect both infections, one of these diagnoses can easily be missed or delayed. Interestingly, patients with TB presented with the lowest mortality rate in this study, though theTB mortality of 10% found in this study was still high. The implementation of a package of diagnosis such as the one provided in this study promotes rapid start of ART while also allowing for appropriate delay of ART initiation in certain situations (e.g. if cryptococcal meningitis is detected in ART-naive patients), as is recommended by the WHO guidelines for managing advanced HIV disease.[3]. Our study has several limitations. It was not designed to directly evaluate the impact of these interventions on patient mortality. However, we were able to document a high mortality at 30-day follow up. Longer patient follow-up might be helpful to identify the long-term outcomes after the introduction of these tests in addition to analyzing the causes of mortality among HIV patients, especially those due to specific opportunistic infections, including tuberculosis diagnosed without bacteriological confirmation[31]. Second, some samples were not collected or processed due to errors during sampling procedures, inability of the patient to provide urine, or samples not taken to the laboratory. Nevertheless, almost 95% of the individuals provided urine samples and 99% provided blood for testing. Treatment regimens were heterogenic in this study, with challenges related to access to fluconazole, lipid formulation of amphotericin liposomal, amphotericin B deoxycholate and 5-flucytosine. This could have had a negative impact on the outcomes of patients with histoplasmosis and cryptococcosis. Finally, the study findings apply to the Paraguayan setting, where HIV care is largely centralized in one hospital and the results are influenced by the local epidemiology. Therefore, findings might not be directly generalizable to other Latin American contexts. PAHO is supporting similar studies in other countries to evaluate similar approaches in other settings. Conclusion This study demonstrates the added value of the inclusion of rapid screening with antigen-based tests for the diagnosis of cryptococcosis, histoplasmosis, and TB among HIV individuals with advanced disease who are initiating or returning to care in Paraguay. The intervention was feasible and led to the identification of a large number of patients with OIs, the prevalence of which was associated with lower CD4 cell counts and higher mortality. All cases of OIs occurred in individuals with CD4 counts below 350 CD4/mm 3 . Patients with AHD were significantly more likely to have OIs than those with CD4 count between 200 and 350. However, a substantial proportion (20%) of patients with CD4 counts between 200 and 350 were detected with OIs. Determining the right CD4 cell count threshold for integrating a diagnostic package for opportunistic infections requires a detailed assessment of the local burden of AHD, the frequency of OIs being targeted, and the cost implications and cost-effectiveness for the HIV program. There is a need to ensure the availability of RDAs and the access to treatment for these OIs to reduce HIV-associated mortality. The results of this demonstration project provide valuable evidence which may inform optimization of national policies and updates of national guidelines for PLHIV with advanced HIV. Declarations Ethics approval and consent to participate. Signed written informed consent was sought from each patient before performing any procedure. Consent for publication. Not applicable Availability of data and material Data is available within the manuscript. Competing interests The authors declare no competing interests. Authors’ contribution All authors contributed substantially to the conception, design, analysis, and interpretation of data, and participated in the preparation and review of drafts of this manuscript and gave their final consent to the publication of the final version. Funding This work was partially funded by the CDC-PAHO Agreement: Building Capacity and Networks to Address Emerging Infectious Diseases in the Americas (Award: 6 NU50CK000494-01-04; Funding Opportunity Announcement: CDC-RFA-CK18-1801CONT20). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Disclaimer The findings and conclusions of this article are the intellectual responsibility of its authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention nor the Pan American Health Organization Acknowledgements We would like to acknowledge the staff of the Instituto de Medicina Tropical (IMT) of Asuncion, Paraguay for taking the time and effort to contribute to this research as well as Dr. Tom Chiller (Mycotic Diseases Branch -Centers for Disease Control and Prevention, Atlanta, Georgia, USA) for his continuous support to this initiative. References Medina N, Alastruey-Izquierdo A, Bonilla O, Gamboa O, Mercado D, Pérez JC, et al. A Rapid Screening Program for Histoplasmosis, Tuberculosis, and Cryptococcosis Reduces Mortality in HIV Patients from Guatemala. J Fungi (Basel) [Internet]. 2021 Apr 1 [cited 2023 Jul 10];7(4). Available from: https://pubmed.ncbi.nlm.nih.gov/33916153/ Ministerio de Salud Pública y Bienestar Social. 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HIV-Associated Histoplasmosis Early Mortality and Incidence Trends: From Neglect to Priority. PLoS Negl Trop Dis [Internet]. 2014 Aug 21 [cited 2023 Jul 3];8(8):e3100. Available from: https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003100 Kanyama C, Chagomerana MB, Chawinga C, Ngoma J, Shumba I, Kumwenda W, et al. Implementation of tuberculosis and cryptococcal meningitis rapid diagnostic tests amongst patients with advanced HIV at Kamuzu Central Hospital, Malawi, 2016-2017. BMC Infect Dis [Internet]. 2022 Dec 1 [cited 2023 Jul 3];22(1). Available from: https://pubmed.ncbi.nlm.nih.gov/35247971/ Morínigo C, María D, Barán T, Águeda D, Sarubbi C, Sarita D, et al. Guía Nacional para el manejo de la Tuberculosis Autoridades. World Health Organization. Lateral Flow urine Lipoarabinomannan assay (LF-LAM) for the diagnosis of active tuberculosis in people living with HIV Policy update [Internet]. Vol. 2019. 2019 [cited 2023 Jul 3]. Available from: https://apps.who.int/iris/handle/10665/329479 Rajasingham R, Medina N, Mousquer GT, Caceres DH, Jordan A, Nacher M, et al. Cost-effectiveness evaluation of routine histoplasmosis screening among people living with advanced HIV disease in Latin America and the Caribbean. PLOS global public health [Internet]. 2023 Aug 15 [cited 2024 Jan 6];3(8):e0001861. Available from: https://pubmed.ncbi.nlm.nih.gov/37582115/ Ferreira M de F, Brito-Santos F, Trilles L, Almeida MA, Wanke B, Veloso VG, et al. Cryptococcal antigenemia prevalence and clinical data in HIV-infected patients from the reference centre at INI-FIOCRUZ, Rio de Janeiro, Southeast of Brazil. Mycoses [Internet]. 2020 Feb 1 [cited 2023 Jul 3];63(2):145–50. Available from: https://pubmed.ncbi.nlm.nih.gov/31715053/ Jarvis JN, Harrison TS, Lawn SD, Meintjes G, Wood R, Cleary S. Cost Effectiveness of Cryptococcal Antigen Screening as a Strategy to Prevent HIV-Associated Cryptococcal Meningitis in South Africa. PLoS One [Internet]. 2013 Jul 19 [cited 2023 Jul 3];8(7):e69288. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0069288 Cano-Torres JO, Olmedo-Reneaum A, Esquivel-Sánchez JM, Camiro-Zuñiga A, Pérez-Carrisoza A, Madrigal-Iberri C, et al. Progressive disseminated histoplasmosis in Latin America and the Caribbean in people receiving highly active antiretroviral therapy for HIV infection: A systematic review. Med Mycol [Internet]. 2019 Oct 1 [cited 2023 Jul 3];57(7):791–9. Available from: https://pubmed.ncbi.nlm.nih.gov/30668766/ Boigues BCS, Paniago AMM, Lima GME, Nunes M de O, Uehara SN de O. Clinical outcomes and risk factors for death from disseminated histoplasmosis in patients with AIDS who visited a high-complexity hospital in Campo Grande, MS, Brazil. Rev Soc Bras Med Trop [Internet]. 2018 Mar 1 [cited 2023 Jul 3];51(2):155–61. Available from: https://pubmed.ncbi.nlm.nih.gov/29768547/ Nacher M, Leitao TS, Gómez BL, Couppié P, Adenis A, Damasceno L, et al. The Fight against HIV-Associated Disseminated Histoplasmosis in the Americas: Unfolding the Different Stories of Four Centers. Journal of Fungi 2019, Vol 5, Page 51 [Internet]. 2019 Jun 17 [cited 2023 Jul 3];5(2):51. Available from: https://www.mdpi.com/2309-608X/5/2/51/htm Bongomin F, Kwizera R, Denning DW. Getting Histoplasmosis on the Map of International Recommendations for Patients with Advanced HIV Disease. Journal of Fungi [Internet]. 2019 Sep 1 [cited 2023 Jul 3];5(3). Available from: /pmc/articles/PMC6787619/ Basso RP, Poester VR, Benelli JL, Stevens DA, Xavier MO. Disseminated Histoplasmosis in Persons with HIV/AIDS, Southern Brazil, 2010–2019. Emerg Infect Dis [Internet]. 2022 Mar 1 [cited 2023 Nov 12];28(3):721. Available from: /pmc/articles/PMC8888216/ Falci DiR, Monteiro AA, Braz Caurio CF, Magalhães TCO, Xavier MO, Basso RP, et al. Histoplasmosis, An Underdiagnosed Disease Affecting People Living With HIV/AIDS in Brazil: Results of a Multicenter Prospective Cohort Study Using Both Classical Mycology Tests and Histoplasma Urine Antigen Detection. Open Forum Infect Dis [Internet]. 2019 Apr 13 [cited 2023 Jul 10];6(4). Available from: https://pubmed.ncbi.nlm.nih.gov/30997365/ Cáceres DH, Gómez BL, Tobón ÁM, Restrepo Á, Chiller T, Lindsley MD, et al. Tackling Histoplasmosis Infection in People Living with HIV from Latin America: From Diagnostic Strategy to Public Health Solutions. Journal of Fungi [Internet]. 2023 May 1 [cited 2023 Jul 3];9(5). Available from: /pmc/articles/PMC10218911/ Esmail A, Pooran A, Sabur NF, Fadul M, Brar MS, Oelofse S, et al. An Optimal Diagnostic Strategy for Tuberculosis in Hospitalized HIV-Infected Patients Using GeneXpert MTB/RIF and Alere Determine TB LAM Ag. J Clin Microbiol [Internet]. 2020 Oct 1 [cited 2023 Jul 3];58(10). Available from: https://pubmed.ncbi.nlm.nih.gov/32727831/ Belaunzarán-Zamudio PF, Caro-Vega YN, Shepherd BE, Rebeiro PF, Crabtree-Ramírez BE, Cortes CP, et al. The Population Impact of Late Presentation With Advanced HIV Disease and Delayed Antiretroviral Therapy in Adults Receiving HIV Care in Latin America. Am J Epidemiol [Internet]. 2020 Jun 1 [cited 2023 Jul 3];189(6):564–72. Available from: https://pubmed.ncbi.nlm.nih.gov/31667488/ Tables Table 1 . Baseline characteristics of the screened patients between August 2021 and June 2022. Characteristics Total 491 (100%) With OI 162 (33%) Without-OI 329 (67%) P value, x 2 Sex n % n % n % Male 365 74 127 78 238 72 0.090 Female 126 26 35 22 91 28 Age Median [IQR] 37 [30-46] 38 [31-44] 37 [30-46] 0.850 Residence Rural 158 32 56 35 102 31 0.300 Urban 283 58 86 53 197 60 Unknown 50 10 20 12 30 9 Patient group * A 68 14 7 4 61 19 <0.0001 B 423 86 155 96 268 82 New HIV diagnosis Yes 217 44 68 42 149 45 0.275 No 274 56 94 58 180 55 CD4 cell count < 50 150 31 67 41 83 25 350 27 6 0 0.0 27 8 unknown± 9 2 2 1 7 2 * Group A: asymptomatic PLHIV with CD4 count 90 days. Group B: symptomatic PLHIV regardless of using ART or CD4 count. ± Patients without a recent CD4 cell count at the time of the opportunistic infections screening. Table 2. Frequency of opportunistic infection based on CD4 cell count*. Opportunistic infection CD4 cell count Unknown ± Overall 350 Histoplasmosis + 43 (9%) 20 ( 14%) 13 (11%) 4 (4%) 5 (7%) 0 1 (13%) Screened 464 144 116 103 68 25 8 Cryptococcosis + 52 (11%) 23 ( 16%) 16 (14%) 11 (10%) 2 (3%) 0 0 Screened 485 148 117 110 74 27 9 Tuberculosis + 92 ( 19%) 41 (28%) 21 (18%) 20 (19%) 9 (13%) 0 1 (14.3%) Screened 474 145 117 108 71 26 7 * All cases of cryptococcosis and tuberculosis cases were included regardless of the diagnostic assay. The table does not discriminate multiple infections. ± Patients without a recent CD4 cell count at the time of the opportunistic infections screening. Table 3 . Positivity of the tests used for screening of opportunistic infections . Diagnostic assay Histoplasmosis (n=43) Tested + % Urine Ag 464 43 9% Cryptococcosis (n=52)* Serum LFA-CrAg 484 51 11% CSF LFA-CrAg 34 21 62% CSF culture 22 11 50% CSF India ink 23 4 17.4% Tuberculosis (n=92) TB-LAM 467 72 15% TB GeneXpert 204 35 17% TB Culture 102 22 22% TB-LAM + GeneXpert 197 62 31% *For one patient, culture was done for diagnosis, reason why no CrAg LFA in sera was performed Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3938634","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":274352264,"identity":"ede391a4-d998-41b2-bab7-519a9e3d9c59","order_by":0,"name":"Gloria Aguilar","email":"","orcid":"","institution":"National HIV Program","correspondingAuthor":false,"prefix":"","firstName":"Gloria","middleName":"","lastName":"Aguilar","suffix":""},{"id":274352265,"identity":"2af0a1c6-de5b-48ac-a6e7-aac0feac98c2","order_by":1,"name":"Gladys Lopez","email":"","orcid":"","institution":"National HIV 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03:29:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3938634/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3938634/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51566072,"identity":"5d91c59a-e88c-4532-98cf-e1b2df87b785","added_by":"auto","created_at":"2024-02-23 19:11:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":207057,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of opportunistic infections based on CD4 cells count.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOI = opportunistic infections\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3938634/v1/6950c351b30d06a480b0e7d2.png"},{"id":51566073,"identity":"2d8316fb-9d8f-4729-98b8-7ee98671e06f","added_by":"auto","created_at":"2024-02-23 19:11:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":207134,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMortality at 30 days in the cohort of patients screened for opportunistic infection in Paraguay.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Patients with and without opportunistic infections; (B) Patients with tuberculosis, cryptococcal disease, histoplasmosis, and with multiple opportunistic infections.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3938634/v1/2bcb45fc69353b4007ccea56.png"},{"id":51566535,"identity":"5ada13ac-a3fe-4231-bd9d-f6e3106ad1be","added_by":"auto","created_at":"2024-02-23 19:19:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":911812,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3938634/v1/a2d764fe-cf80-48a1-bbde-2dc76ee95ea3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementation of a rapid diagnostic assay package for Cryptococcosis, Histoplasmosis and Tuberculosis in People Living with HIV in Paraguay","fulltext":[{"header":"Introduction","content":"\u003cp\u003eExpanded HIV testing and rapid initiation of antiretroviral therapy (ART) can reduce advanced HIV disease (AHD) which is defined by the World Health Organization (WHO) as those with a CD4 cells count below 200 cells/mm\u003csup\u003e3\u003c/sup\u003e or WHO stage 3 or 4 illness in adults and adolescents [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Routine screening for opportunistic infections amongst patients with AHD can increase early detection of individuals who need urgent management to reduce deaths [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Paraguay in 2020, an estimated 16, 233 people were living with HIV (PLHIV). Of these, 89% had been diagnosed, 70% were on ART and 49% were virally suppressed with an undetectable viral load. In 2021, 36% of PLHIV with a recent diagnosis presented with advanced HIV disease (AHD) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePLHIV with AHD are at higher risk of opportunistic infections (OIs), including cryptococcosis, histoplasmosis, and tuberculosis (TB)[\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The main challenges in identifying these infections are the non-specificity of clinical signs and symptoms, a low clinical suspicion for fungal infections, and limited access to rapid and accurate diagnostic tests [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Conventional laboratory methods for the diagnosis of these OIs, such as culture or histopathology, present several limitations, including the need for complex laboratory infrastructure, trained professionals, and long turnaround time for results, particularly for diagnosis of histoplasmosis and tuberculosis[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWHO recommends the use of antigen-based tests for the rapid diagnosis of cryptococcosis, histoplasmosis, and TB among PLHIV with AHD[\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The use of LAM is recommended for all individuals with signs and symptoms of tuberculosis (TB), as well as for admitted asymptomatic patients with \u0026lt;\u0026thinsp;200 cell/ mm\u003csup\u003e3\u003c/sup\u003e or outpatients with \u0026lt;\u0026thinsp;100 cell4/ mm\u003csup\u003e3\u003c/sup\u003e. WHO also recommends the detection \u003cem\u003eof Cryptococcus\u003c/em\u003e antigen (CrAg) and \u003cem\u003eHistoplasma\u003c/em\u003e antigen (HisAg) in individuals with AHD. In Paraguay, national screening of TB in PLHIV has increased from 33% in 2010 to 86% in 2018. In 2020, 8% of all HIV cases registered had a diagnosis of TB[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Cryptococcosis and histoplasmosis are endemic mycoses in the region, but the burden of these diseases in Paraguay is unknown.\u003c/p\u003e \u003cp\u003ePrevious reports have shown that implementing rapid diagnostics assays (RDA) for OIs can positively impact patient care[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The use of these assays has been shown to increase the number of cases diagnosed and reduce mortality[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Currently, there are commercially available RDAs, which have facilitated the implementation of rapid diagnostics for cryptococcosis, histoplasmosis, and TB. These assays, including immunoassays (EIA) and lateral flow assays (LFA) support diagnosis of disease through detection of circulating antigen (Ag)Commercial assays are also available for the detection of DNA, including the Biofire\u0026reg; FilmArray\u0026reg; for the diagnosis of cryptococcosis and TB and the Cepheid\u0026rsquo;s, GeneXpert\u0026reg; Systems for the diagnosis of TB.\u003c/p\u003e \u003cp\u003eThis report describes the results from implementation of a package of diagnostic assays for the detection of cryptococcosis, histoplasmosis, and TB in PLHIV at the Instituto de Medicina Tropical (IMT) in Asuncion, Paraguay. This health facility provides care for 72% of the HIV patients enrolled in care at the national level Paraguay. We also describe the prevalence of cryptococcosis, histoplasmosis, and TB, and analyze the 30-day survival of patients with these infections and for all enrolled patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003ePLHIV were prospectively enrolled at the IMT in Asuncion, Paraguay from August 2021 to July 2022. Patients were recruited from the emergency room, inpatient ward, and the outpatient HIV clinic. We included adults over the age of 18 years who consented to participate. Two groups were defined, the first included asymptomatic PLHIV with a CD4 count of less than 350 cells/mm\u003csup\u003e3\u003c/sup\u003e newly diagnosed with HIV infection or re-engaged in care after being without ART for more than 90 days (Group A). The second group included symptomatic PLHIV regardless of ART status or CD4 count (Group B). Symptomatic PLHIV included those patients with any symptom suggestive of systemic infections within the last 14 days (fever, cough, expectoration, weight loss, night sweats, altered mental status, headache, focal neurological signs, lymphadenopathies, or extensive mucosal or skin lesions).\u003c/p\u003e \u003cp\u003eIndividuals were excluded if less than 18 years old, were HIV uninfected or if they had received active treatment during the last 2 weeks for TB and/or systemic fungal diseases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eLaboratory procedures and case definitions\u003c/h2\u003e \u003cp\u003eFor asymptomatic individuals, a CD4 count was performed if the patient did not have a previous CD4 count in the last three months. All patients with respiratory symptoms and sputum production were asked to provide a sputum specimen for GeneXpert MTB/RIF per Paraguay National TB Program guidelines [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMicroscopic analysis, culture, and molecular testing by GeneXpert MTB/RIF were done on respiratory specimens. Complementary analysis such as the Film Array\u0026reg; (Biom\u0026eacute;rieux, Marcy-l\u0026rsquo;\u0026Eacute;toile, France) were performed at the attending clinician\u0026rsquo;s request and in those patients suspected of extra pulmonary infections caused by mycobacteria or others OIs. The clinical management and treatment for any diagnosed OIs were provided by the attending clinician per local practice and national guidelines.\u003c/p\u003e \u003cp\u003eLaboratory assays for cryptococcosis, histoplasmosis, and TB were done following the manufacturer\u0026rsquo;s instructions. \u003cem\u003eCryptococcus\u003c/em\u003e Ag (CrAg) was detected in sera using a commercial LFA kit (CrAg\u0026reg; LFA, IMMY, Norman, OK, US). In patients with positive CrAg, the laboratory requested cerebrospinal fluid (CSF) specimens for CrAg LFA testing to rule out \u003cem\u003eCryptococcus\u003c/em\u003e meningitis (CM). India link and CSF fungal culture were also performed on CSF when available. Detection of \u003cem\u003eHistoplasma\u003c/em\u003e urinary antigen (HGM) was performed using the Clarus \u003cem\u003eHistoplasma\u003c/em\u003e GM EIA (IMMY, Norman, OK, US), specimens were tested using the standard curve method. A positive result was considered if the specimen presented a concentration of HGM higher or equal to 0.2 ng/ml. For TB, lipoarabinomannan Ag (LAM) was tested in urine (DETERMINE TB LAM Ag, Abbott, Maine, USA). LAM was defined as positive using the grade one cutoff on the manufacturer\u0026rsquo;s post-2014 reference card.\u003c/p\u003e \u003cp\u003eCases were defined as follows: (i) \u003cem\u003eCryptococcosis\u003c/em\u003e: a positive CrAg in sera. (ii) \u003cem\u003eCryptococcus\u003c/em\u003e meningitis: a positive CrAg, Indian ink, or culture in CSF. (iii) \u003cem\u003eHistoplasmosis\u003c/em\u003e: a positive HGM test or other laboratory evidence of histoplasmosis such as positive histopathology or culture and (iv) Bacteriologically confirmed TB: culture-positive, or a WHO-recommended rapid molecular test such as Xpert MTB/RIF, or a positive TB-LAM test.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eProtocol training, data collection, and monitoring\u003c/h2\u003e \u003cp\u003ePrior to patient enrollment, the study staff were trained in appropriate clinical practices, specimen collection, and performing laboratory tests to assure the standard quality of the laboratory procedures. The local study coordinator undertook training sessions with the hospital staff to ensure protocol compliance. Bi-monthly meetings were held to follow protocol progress. A standard case report form was designed using EPI-INFO for data collection of demographic and clinical characteristics, test results and 30-days outcome. Patients unable to be contacted after at least three phone calls or domiciliary visits were considered lost-to-follow-up.\u003c/p\u003e \u003cp\u003eCross-checks with the national HIV database, the national TB database, and the death registry, were done regularly by the National AIDS Program to evaluate accuracy of study data.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cem\u003eEthical approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe IMT ethical committee, and the Pan American Health Organization Ethical Research Committee (PAHOERC) approved the protocol under register PAHOERC.0347.01. Signed written consent was sought from each patient before performing any procedure. No personal identifiable information was collected in the database used for the analysis. \u0026nbsp;Data was compiled by trained professionals and stored in a secure database. CDC staff were determined to be non-engaged in the pilot screening activities and therefore the pilot was determined to be exempt from Centers for Disease Control and Prevention (CDC) IRB review.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStatistical Package for the Social Sciences, version 25.0 (SPSS Inc., Chicago, IL, USA), was used for analysis. Categorical variables were summarized as counts and percentages. Continuous variables were summarized using medians and their corresponding interquartile ranges (IQRs). We assessed the association between baseline characteristics and the presence of opportunistic infections at admission using chi-square, fisher\u0026rsquo;s exact test (categorical variables) and Wilcoxon rank-sum test (continuous variables). A \u003cem\u003ep\u003c/em\u003e value \u0026lt;0.05 was considered statistically significant.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eStudy population and opportunistic infections\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBetween August 2021 to June 2022, a total of 491 PLHIV were enrolled for screening; 365 (74%) were male, 278 (57%) were aged less than 40 years and 58% resided in urban areas (\u003cstrong\u003eTable 1\u003c/strong\u003e). At the time of screening,\u0026nbsp;217 (44%) were newly diagnosed with HIV infection. Three hundred and eighty-one patients (78%) were detected with AHD based on CD4 cell count (\u0026lt;200 cells/mm3) only.\u003c/p\u003e\n\u003cp\u003eOut of the 491 patients enrolled, 162 (33%) were diagnosed with at least one of the OIs being screened for. Of these 92 (19%) had a diagnosis of TB, 52 (11%) had cryptococcosis (51 diagnosed by serum LFA-CrAg and one through culture) and 43 (9%) had histoplasmosis. Among the 162 patients with a diagnosed OI, 23 patients (14%) had multiple OIs (histoplasmosis and TB in 16 patients (70%); cryptococcosis\u0026nbsp;and TB in 4 patients (17%); cryptococcosis and histoplasmosis in one (4%); triple infection in two patients (9%).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Comparing patients with (n=162) and without any of these three OIs (n=329), the median CD4 cell count was significantly lower in patients with OIs than those without OIs (median CD4 cell count 59 cells/mm\u003csup\u003e3\u003c/sup\u003e vs. 106 cells/mm\u003csup\u003e3\u0026nbsp;\u003c/sup\u003erespectively, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; 0.0001). In asymptomatic patients with CD4 \u0026lt;350 cells/mm\u003csup\u003e3\u003c/sup\u003e (group A, n=68), seven patients (10%) were diagnosed with an OI. Of these, one had cryptococcosis without meningitis,two had histoplasmosis, three had TB and one had TB and histoplasmosis co-infection. In contrast, in symptomatic patients (group B, n=423), 155 (37%) were diagnosed with an OI (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; 0.0001) \u003cstrong\u003e(Table 1)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAmong patients with CD4 \u0026lt;200mm\u003csup\u003e3\u003c/sup\u003e, the frequency of the targeted OIs was 38% (n=145). Among patients with CD4 counts between 200 and 350/mm\u003csup\u003e3\u003c/sup\u003e, the frequency of OIs was 20% (P = \u003cem\u003e0.0035\u003c/em\u003e) (\u003cstrong\u003eFigure 1\u003c/strong\u003e). All targeted OIs were found\u0026nbsp;in patients with CD4 \u0026le; 350/mm\u003csup\u003e3\u003c/sup\u003e. The frequency of OIs increased as the count of CD4 cells decreased (\u003cstrong\u003eTable 2\u003c/strong\u003e). Two cases of OI (one histoplasmosis and one tuberculosis) occurred in patients without a CD4 cell count. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOpportunistic infection diagnosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor histoplasmosis screening, 464 of 491 (95%) patients were tested for \u003cem\u003eHistoplasma\u0026nbsp;\u003c/em\u003eantigen detection in urine (\u003cstrong\u003eTable 3\u003c/strong\u003e). Of these, 43 (9%) tested positive. For those not tested, lack of referral of urine to the laboratory for testing was given as the main cause. For \u003cem\u003eCryptococcus\u003c/em\u003e screening, 484 of 491 (99%) patients were tested using CrAg LFA in sera, 51 (10%) were positive. One patient, for whom serum CrAg testing was not conducted, was diagnosed with cryptococcal meningitis through culture and Indian ink examination of cerebrospinal fluid (CSF). Among the 51 patients with positive CrAg in sera, testing of cerebrospinal samples (CSF) was done in 34 patients (67%). Twenty-one of the 34 (62%) CSF samples tested positive for CrAg, confirming meningitis. Detection of CrAg in CSF samples by the LFA-CrAg assay yielded a higher positivity rate than did CSF culture (62% vs. 50%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Of all enrolled patients, 467 (95%) were screened with TB-LAM, 204 (42%) with GeneXpert, and 102 (21%) were tested by culture. Of these, 72 (15%), 35 (17%), and 22 (22%) were positive, respectively. The highest positivity rate was observed in patients receiving both TB-LAM and GeneXpert testing (\u003cstrong\u003eTable 3\u003c/strong\u003e). In this group of 197 patients, a total of 62 TB cases were diagnosed. Among them, 29 (47%) were diagnosed solely through TB-LAM, 15 (24%) through GeneXpert alone, and 29% (n=18, 29%) through a combination of both tests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTreatment\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;and outcomes\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 92 cases diagnosed with tuberculosis, 83 (90%) received antituberculosis treatment. Of the 43 histoplasmosis cases, 36 (84%) initiated antifungal treatment, (21 with amphotericin B deoxycholate, 12 with itraconazole, three with fluconazole). For cryptococcosis (n=52), all patients initiated antifungal treatment for either cryptococcal meningitis or non-meningeal cryptococcosis based on confirmation of cryptococcal meningitis and clinical judgment; (31 with amphotericin B and fluconazole, 21 with fluconazole for pre-emptive treatment). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf all enrolled patients, 486 were followed prospectively for 30-days. Mortality in this period was 10% (49 patients), including 26 (53%) patients with an OI diagnosed in this study (eight cryptococcosis, seven tuberculosis, six histoplasmosis, and five multiple opportunistic infections). Patients with OIs had significantly higher mortality than patients without opportunistic infections (16% vs. 7%; \u003cem\u003ep\u003c/em\u003e = 0.002). The highest mortality rate (25%) was observed in patients with histoplasmosis, followed by multiple opportunistic infections (22%), cryptococcosis (18%), and tuberculosis (10%) (p = 0.004). For those with confirmed cryptococcal meningitis, the mortality rate was 19%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this prospective study, one out of three PLHIV with advanced HIV or new HIV diagnosis had cryptococcosis, histoplasmosis or TB. Routine screening using\u0026nbsp;rapid diagnostic assays provided early detection of these OIs. Here, we found that most PLHIV enrolled had AHD (79%). As shown in Figure 2, the OIs evaluated in this study were more frequent in patients with very low CD4 cell counts (\u0026lt; 50 cells/mm\u003csup\u003e3\u003c/sup\u003e); all detected cases of the targeted OIs were in patients with \u0026le; 350 cells/mm\u003csup\u003e3\u003c/sup\u003e. The WHO recommends screening for CrAg in patients with \u0026lt;200 cells/mm\u003csup\u003e3\u003c/sup\u003e and for TB LAM \u0026lt;100 cells/mm\u003csup\u003e3\u003c/sup\u003e among outpatients as well as any symptomatic inpatients[6,19]. Our findings align with results from a recent analysis in Guatemala, in which 95% of OIs were diagnosed using a 350 CD4 threshold in a screening program for newly HIV diagnosed patients\u0026nbsp;[13]. When considering an appropriate CD4 cell count threshold for implementing this diagnostic package for opportunistic infections, program planners must balance the burden of AHD and of the targeted OIs, while also considering the cost implications for HIV programs. A study in 2023 by Rajasingham and colleges assessed the cost-effectiveness of integrating Histoplasma antigen testing in patients with AHD at a large scale,and estimated that it is cost-effective\u0026nbsp;[20]. \u0026nbsp;However, the public health impact, and cost of an approach that targets individuals with CD4 counts between 200 and 350 for routine screening with these rapid OI diagnostics requires additional evaluation and should be weighed by program planners in the context of the local HIV and OI burden and resource availability.\u0026nbsp;[13]\u003c/p\u003e\n\u003cp\u003eData on the burden of these diseases in Paraguay is historically scarce. The overall frequency of CrAg in serum samples in the present study (11%) is similar to that reported in Brazil with a frequency of 11.2% in patients with AHD[21]. Several studies have reported the diagnostic value of the LFA in detecting cryptococcosis, including in asymptomatic patients. \u003cem\u003eCryptococcus\u003c/em\u003e antigenemia is a well described risk factor for developing cryptococcal meningitis, and requires antifungal therapy tailored to whether concurrent CM is confirmed or suspected\u0026nbsp;[14,22]. Here, we found that 62% of the serum CrAg positive cases had CM. Within 30 days of follow up 19% of serum CrAg positive patients had died, a result which emphasizes the need for routine and rapid access to appropriate antifungal treatment for patients with cryptococcosis\u003c/p\u003e\n\u003cp\u003eHistoplasmosis imposes a significant burden in this region, with prevalences of 10% and higher reported among individuals with advanced HIV disease in the region[23,24]. Co-occurrence with TB and other opportunistic infections is common, highlighting the need for improved capacity to detect histoplasmosis as part of the routine workup of individuals with advanced HIV disease in this region[25,26].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur screening strategy classified patients based on the presence or absence of general symptoms, which is a key clinical indicator. At the time of screening, 5% of the asymptomatic patients with AHD received a diagnosis of an OI. In the absence of this strategy, these cases may have progressed to severe disease, requiring more complex care \u0026nbsp;with a \u0026nbsp;higher likelihood of negative outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUsing Histoplasma Ag testing, a total of 43 people with histoplasmosis were detected. It is important to highlight that histoplasmosis was the only OI in 24 patients, in the remaining 19 (44% patients), coinfection with histoplasmosis and other OIs occurred, TB coinfection being the most common (18 of 19 co-infected). This coinfection is commonly reported in Latin America. Several case series and cohorts of PLHIV report the co-occurrence of histoplasmosis-TB ranging from 2% to 38% [11]. A recent review of studies in Latin America which used \u003cem\u003eHistoplasma\u003c/em\u003e Ag testing showed that use of the test had a positive impact on case detection, increased diagnostic yield, and in some reports doubled the number of diagnosed cases [27,28]. Additionally, a reduction in mortality of patients diagnosed with histoplasmosis was reported when using rapid antigen testing [29].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur implementation study used urine antigen testing to detect histoplasmosis, and a small number of cases could have been missed due to challenges in collection of urine, or due to problems in the transport of urine specimens to the laboratory. The package of diagnosis provided here could be further improved by the incorporation of point of care LFA for histoplasmosis.\u003c/p\u003e\n\u003cp\u003eThere is limited data on how to optimally integrate different assays for TB in the region. In this study, when Xpert\u0026reg; MTB/RIF Ultra - Cepheid and TB-LAM tests were both used, the urine TB-LAM test had an incremental yield of 47%. The combination of both assays identified a higher proportion of tuberculosis cases (62 of 197 patients tested). These findings are consistent with a multicenter study in which the combination of TB-LAM and GeneXpert tests had the highest sensitivity[30]. Thus, our data supports the importance of incorporating both tests into routine health care for PLHIV. Additional studies including qualitative methods are needed to identify the challenges and gaps in integrating these tests in the package of care for PLHIV.\u003c/p\u003e\n\u003cp\u003eOverall, the 30-day mortality in this cohort was high and, as expected, was higher among patients with opportunistic infections. Patients with histoplasmosis and those with multiple OIs had the highest mortality rates of 25% and 22% respectively. Most of these patients were highly immunocompromised, with the median CD4 counts the lowest among patients with multiple OIs (median 42 cells/mm\u003csup\u003e3\u003c/sup\u003e). The most frequent common co-infection was histoplasmosis and TB (70%). Treatment of histoplasmosis/TB coinfection is challenging due to the pharmacokinetic drug-drug interactions of itraconazole and some common TB medicines [8]. Concerning histoplasmosis, clinical manifestations are nonspecific and often resemble those produced by other common infections such as TB. In the absence of a strategy to accurately detect both infections, one of these diagnoses can easily be missed or delayed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterestingly, patients with TB presented with the lowest mortality rate in this study, though theTB mortality of 10% found in this study was still high. The implementation of a package of diagnosis such as the one provided in this study promotes rapid start of ART while also allowing for appropriate delay of ART initiation in certain situations (e.g. if cryptococcal meningitis is detected in ART-naive patients), as is recommended by the WHO guidelines for managing advanced HIV disease.[3].\u003c/p\u003e\n\u003cp\u003eOur study has several limitations. It was not designed to directly evaluate the impact of these interventions on patient mortality. However, we were able to document a high mortality at 30-day follow up. Longer patient follow-up might be helpful to identify the long-term outcomes after the introduction of these tests in addition to analyzing the causes of mortality among HIV patients, especially those due to specific opportunistic infections, including tuberculosis diagnosed without bacteriological confirmation[31]. Second, some samples were not collected or processed due to errors during sampling procedures, inability of the patient to provide urine, or samples not taken to the laboratory. Nevertheless, almost 95% of the individuals provided urine samples and 99% provided blood for testing. Treatment regimens were heterogenic in this study, with challenges related to access to fluconazole, lipid formulation of amphotericin liposomal, amphotericin B deoxycholate and 5-flucytosine. This could have had a negative impact on the outcomes of patients with histoplasmosis and cryptococcosis. Finally, the study findings apply to the Paraguayan setting, where HIV care is largely centralized in one hospital and the results are influenced by the local epidemiology. Therefore, findings might not be directly generalizable to other Latin American contexts. PAHO is supporting similar studies in other countries to evaluate similar approaches in other settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates the added value of the inclusion of rapid screening with antigen-based tests for the diagnosis of cryptococcosis, histoplasmosis, and TB among HIV individuals with advanced disease who are initiating or returning to care in Paraguay. The intervention was feasible and led to the identification of a large number of patients with OIs, the prevalence of which was associated with lower CD4 cell counts and higher mortality. All cases of OIs occurred in individuals with CD4 counts below 350 CD4/mm\u003csup\u003e3\u003c/sup\u003e. Patients with AHD were significantly more likely to have OIs than those with CD4 count between 200 and 350. \u0026nbsp;However, a substantial proportion (20%) of patients with CD4 counts between 200 and 350 were detected with OIs. \u0026nbsp;Determining the right CD4 cell count threshold for integrating a diagnostic package for opportunistic infections requires a detailed assessment of the local burden of AHD, the frequency of OIs being targeted, and the cost implications and cost-effectiveness for the HIV program. There is a need to ensure the availability of RDAs and the access to treatment for these OIs to reduce HIV-associated mortality. The results of this demonstration project provide valuable evidence which may inform optimization of national policies and updates of national guidelines for PLHIV with advanced HIV. \u0026nbsp;\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSigned written informed consent was sought from each patient before performing any procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available within the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed substantially to the conception, design, analysis, and interpretation of data, and participated in the preparation and review of drafts of this manuscript and gave their final consent to the publication of the final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was partially funded by the CDC-PAHO Agreement: Building Capacity and Networks to Address Emerging Infectious Diseases in the Americas (Award: 6 NU50CK000494-01-04; Funding Opportunity Announcement: CDC-RFA-CK18-1801CONT20). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimer\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings and conclusions of this article are the intellectual responsibility of its authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention nor the Pan American Health Organization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the staff of the Instituto de Medicina Tropical (IMT) of Asuncion, Paraguay for taking the time and effort to contribute to this research as well as Dr. Tom Chiller (Mycotic Diseases Branch -Centers for Disease Control and Prevention, Atlanta, Georgia, USA) for his continuous support to this initiative.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMedina N, Alastruey-Izquierdo A, Bonilla O, Gamboa O, Mercado D, P\u0026eacute;rez JC, et al. 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Disseminated Histoplasmosis (DH) Before and After the Implementation of Urine Antigen Detection Elisa (UADE) in an HIV clinic in Guatemala. ICCAC, San Francisco. 2012. \u003c/li\u003e\n\u003cli\u003eAdenis A, Nacher M, Hanf M, Vantilcke V, Boukhari R, Blachet D, et al. HIV-Associated Histoplasmosis Early Mortality and Incidence Trends: From Neglect to Priority. PLoS Negl Trop Dis [Internet]. 2014 Aug 21 [cited 2023 Jul 3];8(8):e3100. Available from: https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003100\u003c/li\u003e\n\u003cli\u003eKanyama C, Chagomerana MB, Chawinga C, Ngoma J, Shumba I, Kumwenda W, et al. Implementation of tuberculosis and cryptococcal meningitis rapid diagnostic tests amongst patients with advanced HIV at Kamuzu Central Hospital, Malawi, 2016-2017. BMC Infect Dis [Internet]. 2022 Dec 1 [cited 2023 Jul 3];22(1). Available from: https://pubmed.ncbi.nlm.nih.gov/35247971/\u003c/li\u003e\n\u003cli\u003eMor\u0026iacute;nigo C, Mar\u0026iacute;a D, Bar\u0026aacute;n T, \u0026Aacute;gueda D, Sarubbi C, Sarita D, et al. Gu\u0026iacute;a Nacional para el manejo de la Tuberculosis Autoridades. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Lateral Flow urine Lipoarabinomannan assay (LF-LAM) for the diagnosis of active tuberculosis in people living with HIV Policy update [Internet]. Vol. 2019. 2019 [cited 2023 Jul 3]. Available from: https://apps.who.int/iris/handle/10665/329479\u003c/li\u003e\n\u003cli\u003eRajasingham R, Medina N, Mousquer GT, Caceres DH, Jordan A, Nacher M, et al. Cost-effectiveness evaluation of routine histoplasmosis screening among people living with advanced HIV disease in Latin America and the Caribbean. PLOS global public health [Internet]. 2023 Aug 15 [cited 2024 Jan 6];3(8):e0001861. Available from: https://pubmed.ncbi.nlm.nih.gov/37582115/\u003c/li\u003e\n\u003cli\u003eFerreira M de F, Brito-Santos F, Trilles L, Almeida MA, Wanke B, Veloso VG, et al. Cryptococcal antigenemia prevalence and clinical data in HIV-infected patients from the reference centre at INI-FIOCRUZ, Rio de Janeiro, Southeast of Brazil. Mycoses [Internet]. 2020 Feb 1 [cited 2023 Jul 3];63(2):145\u0026ndash;50. Available from: https://pubmed.ncbi.nlm.nih.gov/31715053/\u003c/li\u003e\n\u003cli\u003eJarvis JN, Harrison TS, Lawn SD, Meintjes G, Wood R, Cleary S. Cost Effectiveness of Cryptococcal Antigen Screening as a Strategy to Prevent HIV-Associated Cryptococcal Meningitis in South Africa. PLoS One [Internet]. 2013 Jul 19 [cited 2023 Jul 3];8(7):e69288. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0069288\u003c/li\u003e\n\u003cli\u003eCano-Torres JO, Olmedo-Reneaum A, Esquivel-S\u0026aacute;nchez JM, Camiro-Zu\u0026ntilde;iga A, P\u0026eacute;rez-Carrisoza A, Madrigal-Iberri C, et al. Progressive disseminated histoplasmosis in Latin America and the Caribbean in people receiving highly active antiretroviral therapy for HIV infection: A systematic review. Med Mycol [Internet]. 2019 Oct 1 [cited 2023 Jul 3];57(7):791\u0026ndash;9. Available from: https://pubmed.ncbi.nlm.nih.gov/30668766/\u003c/li\u003e\n\u003cli\u003eBoigues BCS, Paniago AMM, Lima GME, Nunes M de O, Uehara SN de O. Clinical outcomes and risk factors for death from disseminated histoplasmosis in patients with AIDS who visited a high-complexity hospital in Campo Grande, MS, Brazil. Rev Soc Bras Med Trop [Internet]. 2018 Mar 1 [cited 2023 Jul 3];51(2):155\u0026ndash;61. Available from: https://pubmed.ncbi.nlm.nih.gov/29768547/\u003c/li\u003e\n\u003cli\u003eNacher M, Leitao TS, G\u0026oacute;mez BL, Couppi\u0026eacute; P, Adenis A, Damasceno L, et al. The Fight against HIV-Associated Disseminated Histoplasmosis in the Americas: Unfolding the Different Stories of Four Centers. Journal of Fungi 2019, Vol 5, Page 51 [Internet]. 2019 Jun 17 [cited 2023 Jul 3];5(2):51. Available from: https://www.mdpi.com/2309-608X/5/2/51/htm\u003c/li\u003e\n\u003cli\u003eBongomin F, Kwizera R, Denning DW. Getting Histoplasmosis on the Map of International Recommendations for Patients with Advanced HIV Disease. Journal of Fungi [Internet]. 2019 Sep 1 [cited 2023 Jul 3];5(3). Available from: /pmc/articles/PMC6787619/\u003c/li\u003e\n\u003cli\u003eBasso RP, Poester VR, Benelli JL, Stevens DA, Xavier MO. Disseminated Histoplasmosis in Persons with HIV/AIDS, Southern Brazil, 2010\u0026ndash;2019. Emerg Infect Dis [Internet]. 2022 Mar 1 [cited 2023 Nov 12];28(3):721. Available from: /pmc/articles/PMC8888216/\u003c/li\u003e\n\u003cli\u003eFalci DiR, Monteiro AA, Braz Caurio CF, Magalh\u0026atilde;es TCO, Xavier MO, Basso RP, et al. Histoplasmosis, An Underdiagnosed Disease Affecting People Living With HIV/AIDS in Brazil: Results of a Multicenter Prospective Cohort Study Using Both Classical Mycology Tests and Histoplasma Urine Antigen Detection. Open Forum Infect Dis [Internet]. 2019 Apr 13 [cited 2023 Jul 10];6(4). Available from: https://pubmed.ncbi.nlm.nih.gov/30997365/\u003c/li\u003e\n\u003cli\u003eC\u0026aacute;ceres DH, G\u0026oacute;mez BL, Tob\u0026oacute;n \u0026Aacute;M, Restrepo \u0026Aacute;, Chiller T, Lindsley MD, et al. Tackling Histoplasmosis Infection in People Living with HIV from Latin America: From Diagnostic Strategy to Public Health Solutions. Journal of Fungi [Internet]. 2023 May 1 [cited 2023 Jul 3];9(5). Available from: /pmc/articles/PMC10218911/\u003c/li\u003e\n\u003cli\u003eEsmail A, Pooran A, Sabur NF, Fadul M, Brar MS, Oelofse S, et al. An Optimal Diagnostic Strategy for Tuberculosis in Hospitalized HIV-Infected Patients Using GeneXpert MTB/RIF and Alere Determine TB LAM Ag. J Clin Microbiol [Internet]. 2020 Oct 1 [cited 2023 Jul 3];58(10). Available from: https://pubmed.ncbi.nlm.nih.gov/32727831/\u003c/li\u003e\n\u003cli\u003eBelaunzar\u0026aacute;n-Zamudio PF, Caro-Vega YN, Shepherd BE, Rebeiro PF, Crabtree-Ram\u0026iacute;rez BE, Cortes CP, et al. The Population Impact of Late Presentation With Advanced HIV Disease and Delayed Antiretroviral Therapy in Adults Receiving HIV Care in Latin America. Am J Epidemiol [Internet]. 2020 Jun 1 [cited 2023 Jul 3];189(6):564\u0026ndash;72. Available from: https://pubmed.ncbi.nlm.nih.gov/31667488/\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. \u003cstrong\u003eBaseline characteristics of the screened patients between August 2021 and June 2022.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"610\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.295081967213115%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u0026nbsp;\u003cbr\u003e\u0026nbsp;491 (100%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.9672131147541%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eWith OI\u003cbr\u003e\u0026nbsp;162 (33%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.770491803278688%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eWithout-OI\u003cbr\u003e\u0026nbsp;329 (67%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value, \u003cem\u003ex\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"bottom\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\" valign=\"bottom\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"bottom\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\" valign=\"bottom\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\" valign=\"bottom\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\" valign=\"bottom\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\" valign=\"bottom\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\"\u003e\n \u003cp\u003e365\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\"\u003e\n \u003cp\u003e238\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.138836772983115%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.071294559099437%\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.444652908067543%\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.634146341463415%\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Median [IQR]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\n \u003cp\u003e[30-46]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\" valign=\"bottom\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\" valign=\"bottom\"\u003e\n \u003cp\u003e[31-44]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\" valign=\"bottom\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\" valign=\"bottom\"\u003e\n \u003cp\u003e[30-46]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" valign=\"top\"\u003e\n \u003cp\u003e0.850\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"top\"\u003e\n \u003cp\u003eResidence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\" valign=\"top\"\u003e\n \u003cp\u003e158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\" valign=\"top\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\" valign=\"top\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.300\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.138836772983115%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Urban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.071294559099437%\" valign=\"top\"\u003e\n \u003cp\u003e283\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.444652908067543%\" valign=\"top\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\" valign=\"top\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\" valign=\"top\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.634146341463415%\" valign=\"top\"\u003e\n \u003cp\u003e197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\" valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.138836772983115%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Unknown\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.071294559099437%\" valign=\"top\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.444652908067543%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.634146341463415%\" valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"top\"\u003e\n \u003cp\u003ePatient group *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.138836772983115%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; B\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.071294559099437%\"\u003e\n \u003cp\u003e423\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.444652908067543%\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.634146341463415%\"\u003e\n \u003cp\u003e268\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"top\"\u003e\n \u003cp\u003eNew HIV diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\"\u003e\n \u003cp\u003e217\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\"\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.275\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.138836772983115%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.071294559099437%\"\u003e\n \u003cp\u003e274\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.444652908067543%\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.634146341463415%\"\u003e\n \u003cp\u003e180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"top\"\u003e\n \u003cp\u003eCD4 cell count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.34426229508197%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026lt; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.295081967213115%\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.78688524590164%\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.98360655737705%\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.62295081967213%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.138836772983115%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;50\u0026ndash;99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.071294559099437%\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.444652908067543%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.634146341463415%\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.138836772983115%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;100\u0026ndash;199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.071294559099437%\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.444652908067543%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.634146341463415%\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.138836772983115%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;200\u0026ndash;350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.071294559099437%\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.444652908067543%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.634146341463415%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.138836772983115%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026gt;350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.071294559099437%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.444652908067543%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.634146341463415%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.138836772983115%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; unknown\u0026plusmn;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.071294559099437%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.444652908067543%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.634146341463415%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.570356472795497%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* Group A: asymptomatic PLHIV with CD4 count \u0026lt;350 cells/mm3, newly HIV diagnosed or re-engaged in care after being \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;without ART for \u0026gt; 90 days. Group B: symptomatic PLHIV regardless of using ART or CD4 count.\u003c/p\u003e\n\u003cp\u003e\u0026plusmn; Patients without a recent CD4 cell count at the time of the opportunistic infections screening.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFrequency of opportunistic infection based on CD4 cell count*.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"681\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.348017621145374%\" colspan=\"2\" rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Opportunistic infection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"66.37298091042584%\" colspan=\"6\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCD4 cell count\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.279001468428781%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnknown\u003c/strong\u003e\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"15\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.371681415929203%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.256637168141594%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 50\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.929203539823009%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e50\u0026ndash;99\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.256637168141594%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e100\u0026ndash;199\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.256637168141594%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e200\u0026ndash;350\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.929203539823009%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;350\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"15\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.509544787077827%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistoplasmosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.838472834067547%\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.866372980910425%\" valign=\"top\"\u003e\n \u003cp\u003e43 \u003cstrong\u003e(9%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"bottom\"\u003e\n \u003cp\u003e20 (\u003cstrong\u003e14%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.572687224669604%\" valign=\"bottom\"\u003e\n \u003cp\u003e13 \u003cstrong\u003e(11%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"bottom\"\u003e\n \u003cp\u003e4 \u003cstrong\u003e(4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"bottom\"\u003e\n \u003cp\u003e5 \u003cstrong\u003e(7%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.572687224669604%\" valign=\"bottom\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.279001468428781%\" valign=\"top\"\u003e\n \u003cp\u003e1 \u003cstrong\u003e(13%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"15\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.375212224108658%\"\u003e\n \u003cp\u003eScreened\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.563667232597624%\" valign=\"top\"\u003e\n \u003cp\u003e464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.242784380305602%\" valign=\"bottom\"\u003e\n \u003cp\u003e144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.224108658743633%\" valign=\"bottom\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.242784380305602%\" valign=\"bottom\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.242784380305602%\" valign=\"bottom\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.224108658743633%\" valign=\"bottom\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.884550084889643%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"15\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"8\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"30\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.509544787077827%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eCryptococcosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.838472834067547%\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.866372980910425%\" valign=\"top\"\u003e\n \u003cp\u003e52 \u003cstrong\u003e(11%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"bottom\"\u003e\n \u003cp\u003e23 (\u003cstrong\u003e16%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.572687224669604%\" valign=\"bottom\"\u003e\n \u003cp\u003e16 \u003cstrong\u003e(14%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"bottom\"\u003e\n \u003cp\u003e11\u003cstrong\u003e(10%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"bottom\"\u003e\n \u003cp\u003e2 \u003cstrong\u003e(3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.572687224669604%\" valign=\"bottom\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.279001468428781%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"15\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.375212224108658%\"\u003e\n \u003cp\u003eScreened\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.563667232597624%\" valign=\"top\"\u003e\n \u003cp\u003e485\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.242784380305602%\" valign=\"bottom\"\u003e\n \u003cp\u003e148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.224108658743633%\" valign=\"bottom\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.242784380305602%\" valign=\"bottom\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.242784380305602%\" valign=\"bottom\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.224108658743633%\" valign=\"bottom\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.884550084889643%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"15\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"8\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"30\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.509544787077827%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eTuberculosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.838472834067547%\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.866372980910425%\" valign=\"top\"\u003e\n \u003cp\u003e92 (\u003cstrong\u003e19%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"bottom\"\u003e\n \u003cp\u003e41 \u003cstrong\u003e(28%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.572687224669604%\" valign=\"bottom\"\u003e\n \u003cp\u003e21 \u003cstrong\u003e(18%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"bottom\"\u003e\n \u003cp\u003e20 \u003cstrong\u003e(19%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.45374449339207%\" valign=\"bottom\"\u003e\n \u003cp\u003e9 \u003cstrong\u003e(13%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.572687224669604%\" valign=\"bottom\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.279001468428781%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003cstrong\u003e\u0026nbsp;(14.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"15\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.375212224108658%\"\u003e\n \u003cp\u003eScreened\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.563667232597624%\" valign=\"top\"\u003e\n \u003cp\u003e474\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.242784380305602%\" valign=\"bottom\"\u003e\n \u003cp\u003e145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.224108658743633%\" valign=\"bottom\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.242784380305602%\" valign=\"bottom\"\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.242784380305602%\" valign=\"bottom\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.224108658743633%\" valign=\"bottom\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.884550084889643%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"15\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"8\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"30\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003eAll cases of\u0026nbsp;cryptococcosis\u0026nbsp;and tuberculosis cases were included regardless of the diagnostic assay. The\u0026nbsp;\u003c/p\u003e\n\u003cp\u003etable does not discriminate multiple infections. \u0026plusmn; Patients without a recent CD4 cell count at the time of the opportunistic infections screening.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e. Positivity of the\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003etests\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;used\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003efor\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;screening\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eof opportunistic infections\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"287\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnostic assay\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"51.21951219512195%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistoplasmosis (n=43)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.612244897959183%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eTested\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.85034013605442%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.53741496598639%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; Urine Ag\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.679442508710801%\" valign=\"bottom\"\u003e\n \u003cp\u003e464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.240418118466899%\" valign=\"bottom\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.299651567944252%\" valign=\"bottom\"\u003e\n \u003cp\u003e9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"51.21951219512195%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCryptococcosis (n=52)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; Serum LFA-CrAg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.679442508710801%\" valign=\"bottom\"\u003e\n \u003cp\u003e484\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.240418118466899%\" valign=\"bottom\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.299651567944252%\" valign=\"bottom\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; CSF LFA-CrAg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.679442508710801%\" valign=\"bottom\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.240418118466899%\" valign=\"bottom\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.299651567944252%\" valign=\"bottom\"\u003e\n \u003cp\u003e62%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; CSF culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.679442508710801%\" valign=\"bottom\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.240418118466899%\" valign=\"bottom\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.299651567944252%\" valign=\"bottom\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; CSF India ink\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.679442508710801%\" valign=\"bottom\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.240418118466899%\" valign=\"bottom\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.299651567944252%\" valign=\"bottom\"\u003e\n \u003cp\u003e17.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"51.21951219512195%\" colspan=\"3\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eTuberculosis (n=92)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; TB-LAM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.679442508710801%\" valign=\"bottom\"\u003e\n \u003cp\u003e467\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.240418118466899%\" valign=\"bottom\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.299651567944252%\" valign=\"bottom\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; TB GeneXpert\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.679442508710801%\" valign=\"bottom\"\u003e\n \u003cp\u003e204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.240418118466899%\" valign=\"bottom\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.299651567944252%\" valign=\"bottom\"\u003e\n \u003cp\u003e17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; TB Culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.679442508710801%\" valign=\"bottom\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.240418118466899%\" valign=\"bottom\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.299651567944252%\" valign=\"bottom\"\u003e\n \u003cp\u003e22%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.78048780487805%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;TB-LAM + GeneXpert\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.679442508710801%\" valign=\"bottom\"\u003e\n \u003cp\u003e197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.240418118466899%\" valign=\"bottom\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.299651567944252%\" valign=\"bottom\"\u003e\n \u003cp\u003e31%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*For one patient, culture was done for diagnosis, reason why no CrAg LFA in sera was performed\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"opportunistic infections HIV, diagnostic, Paraguay","lastPublishedDoi":"10.21203/rs.3.rs-3938634/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3938634/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOpportunistic infections (OIs) are common causes of mortality among people living with HIV (PLHIV). We determined prevalence and 30-day mortality due to histoplasmosis, cryptococcosis, and TB in PLHIV with advanced HIV disease (AHD).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePLHIV 18 years and older, not receiving ART with advanced HIV were enrolled and followed for 30 days. Detection of \u003cem\u003eHistoplasma\u003c/em\u003e Ag (HisAg) in urine was done by enzyme immunoassay (EIA), \u003cem\u003eCryptococcus\u003c/em\u003e antigen (CrAg) was detected in serum and cerebrospinal fluid (CSF) specimens by lateral flow assay (LFA), and lipoarabinomannan (LAM) detection in urine was by LFA (TB LAM) and in sputum by GeneXpert for diagnosis of \u003cem\u003eMycobacterium\u003c/em\u003e infections.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFrom August 2021 to June 2022, 491 PLHIV were enrolled; 482 (98%) had a CD4 result, and 381 patients (79%) were classified with AHD according to CD4 cell count (\u0026lt;\u0026thinsp;200 CD4/mm\u003csup\u003e3\u003c/sup\u003e). Frequency of an OI was 38% (n\u0026thinsp;=\u0026thinsp;145/381). Antigen test positivity rate was 16% (72/467) for TB-LAM, 9% (43/464) for HisAg, and 11% (51/484) for CrAg. Twenty-one of 34 (62%) patients receiving CSF CrAg tests were positive, confirming meningitis. Significant differences in 30-day mortality were observed in patients with an OI (16%) vs no OI (7%) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). Mortality was highest in patients with histoplasmosis (25%), co-infection (22%), cryptococcosis (18% overall; 19% for cryptococcal meningitis), and TB (10%).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eTB and fungal (OIs), including co-infection, were common in PLHIV in Paraguay and had high associated mortality. Laboratories and health facilities need access to CD4 testing and rapid diagnostic assays.\u003c/p\u003e","manuscriptTitle":"Implementation of a rapid diagnostic assay package for Cryptococcosis, Histoplasmosis and Tuberculosis in People Living with HIV in Paraguay","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-23 19:11:02","doi":"10.21203/rs.3.rs-3938634/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-02-29T13:06:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-25T12:10:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"882d89b5-e996-4e33-bf53-e25c152d655e","date":"2024-02-25T09:44:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82bdef70-6373-46d1-80d4-89e37963161b","date":"2024-02-23T17:27:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"ea2fe012-70e9-4bae-821e-5a33c88be2b5","date":"2024-02-22T16:17:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-22T13:29:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-22T13:27:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-02-22T06:51:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-22T06:45:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-02-08T03:26:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d60c796a-bba4-4327-9fd2-431ac814f8ce","owner":[],"postedDate":"February 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-03-26T06:05:07+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-23 19:11:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3938634","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3938634","identity":"rs-3938634","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}