Page 18 - Nursing Matters June 2021 Vol 12

burden of CM, estimated at 162 500 The evolution of CrAg tests overburdened referral hospitals in South
cases (73% of total), resulting in 135 and birth of a national CrAg Africa. As a result of this task shifting,
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900 deaths. Although the incidence screening programme in South primary healthcare (PHC) nurses have
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of CM has declined in resource-rich Africa become primarily responsible for large
countries with close-to-universal ART numbers of HIV-infected patients, and
access, CM is still a problem in many In the past, a cryptococcal latex therefore play a pivotal role in the CrAg
sub-Saharan African countries where agglutination test (CLAT) was used to screening process.
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the HIV prevalence is very high, access detect CrAg in the blood and CSF. 11,12
to healthcare is limited, a large number While the CLAT was previously Important updates to the CrAg screening
of people are still unaware of their considered the gold standard for CrAg process are included in the South
HIV status and interruption of ART is a testing, this is a labour-intensive and African National Department of Health’s
common occurrence. In South Africa, expensive test requiring specialised (NDoH) consolidated guideline for the
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over 30% of people entering into HIV laboratory infrastructure. 11,12 A lateral management of HIV updated in February
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care are diagnosed with AHD and over flow assay (LFA) was developed and 2020. According to this guideline, all
15% have very advanced disease (i.e. a became commercially available in patients with a first positive CrAg test on
CD4 count of <100 cells/µL). 2011. This test format was found to blood now require a lumbar puncture
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have >99% sensitivity and specificity (LP) to exclude CM. PHC nurses who
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Cryptococcal antigen (CrAg) for CrAg detection in the context of manage many of these patients need
screening CM.[13] An LFA is a rapid dipstick test to vigilantly check all screening blood
which is inexpensive and ideal for use CrAg results in their facilities, and
In March 2011, the WHO first for CrAg screening in resource-limited timeously refer those patients needing
recommended screening of HIV-infected settings. An LFA meets all of the WHO’s LPs, in order to ensure early diagnosis
people with a CD4 count of <100 cells/ A.S.S.U.R.E.D. criteria (i.e. affordable, and treatment of CM. Reflex CrAg
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µL using a rapid cryptococcal antigen sensitive, specific, user friendly, rapid or screening results can easily be missed
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(CrAg) test. CrAg, which is a component robust, equipment-free and delivered). as they are not ordered by clinicians.
of the cryptococcal polysaccharide In 2011, the WHO recommended routine Results for Action (RfA) is an electronic
capsule, can be detected in the blood of blood CrAg screening in populations result delivery portal which enables
infected people weeks, or even months, with a high prevalence of cryptococcal South African clinicians to access positive
before the onset of symptomatic CM. antigenaemia using either the CLAT blood CrAg results at facility, subdistrict,
Therefore, a CrAg test can serve as a or LFA. 9,10 The recommendation was and district levels as soon as these results
valuable biomarker for early detection later updated in 2018 to use an LFA for are available. Clinicians can register for
of cryptococcal disease in asymptomatic screening. In 2012, a pilot programme the RfA by going to nicd.ac.za, clicking
patients. A positive blood CrAg test for reflex laboratory-based CrAg on M&E Dashboard and selecting self-
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must be immediately followed by a screening was launched in South Africa. service registration.
lumbar puncture to exclude subclinical The pilot was expanded into a national
or asymptomatic CM. If the patient has screening programme in 2016, so that The NDoH guideline further recommends
no evidence of CM (i.e. cerebrospinal all blood samples with a CD4 count of that following referral for an LP, patients
fluid [CSF] CrAg-negative) soon after <100 cells/µL now automatically receive with a CrAg-negative test on CSF should
screening blood CrAg-positive, pre- a CrAg test. Between February 2017 receive oral pre-emptive fluconazole.
emptive anti-fungal therapy can prevent and September 2020, over 990 000 Many patients are referred back to PHC
progression to CM. reflex CrAg tests were performed, with facilities for their pre-emptive therapy,
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a 6% of those having a positive result. necessitating a good level of knowledge
(Unpublished data, National Institute for on fluconazole prescribing among
Communicable Diseases, 2020) PHC nurses. Among adults, the pre-
emptive fluconazole regimen includes
South Africa’s CrAg The role of the primary an induction phase of 1200 mg daily
screening programme is healthcare nurse in CrAg for 14 days, followed by a consolidation
important for the early screening phase of 800 mg daily for 8 weeks.
The maintenance dose of 200 mg daily
diagnosis of cryptococcal Decentralisation of the ART services, should follow these phases and continue
disease and prevention of together with the nurse-initiated for at least a year. Fluconazole can be
progression to CM. management of ART (NIMART) discontinued when patients have a CD4
programme, has been integral count of >200 cells/µL on ART and viral
in relieving pressure on already- suppression is achieved.

HIV Nursing Matters | June 2021 | page 16