Impact of the introduction of a package of care involving early detection of opportunistic infections, a prospective multicenter cohort study of people living with HIV/AIDS in Brazil

Abstract

Background Opportunistic infections (OIs) significantly contribute to morbidity and mortality in advanced HIV disease. This study evaluates the efficacy of point-of-care (POC) diagnostics for tuberculosis (TB), histoplasmosis, and cryptococcosis in routine HIV care in Brazil. Methods A prospective multicenter cohort study was conducted across five hospitals enrolling people living with HIV (PLHIV) with CD4+ T-cell count <200 cells/mm3 or OI symptoms, regardless of CD4 count, HIV-naïve patients, those initiating treatment, and individuals with unsuppressed viral load lost to follow-up (>3 months). POC tests included VISITECT CD4 Advanced Disease, TB LAM Ag (Abbott), GeneXpert MTB/RIF (Cepheid), Histoplasma antigen LFA (MiraVista), and CrAg LFA (IMMY). Patients were followed at 30 and 90 days. Retrospective data for six months pre-study was collected for comparison. Findings Among 419 PLHIV (55% cisgender men, 44% cisgender women, 1% transgender; mean age: 42 years, SD ± 11.1), 46% had confirmed OIs: TB (34%), cryptococcosis (12%), histoplasmosis (10%). Co-infections were frequent, with TB and histoplasmosis (44%). Cryptococcal meningitis and severe histoplasmosis were diagnosed in 5% and 6%, respectively. TB LAM was positive in 27% of tested patients, with 74% having disseminated TB. POC testing increased detection rates for TB, (1.8-fold) cryptococcosis (2.8-fold), and histoplasmosis (2.8-fold) compared to historical data. Survival rates were 87% at 30 days and 80% at 90 days, with cryptococcal antigenemia associated with higher mortality. Interpretation POC testing improved OI diagnosis, aligning with WHO guidelines. These findings highlight the importance of integrating rapid diagnostics into HIV programs and the need for further research on long-term outcomes. Funding Pan American Health Organization.