Can surveillance data reveal trends in HIV-associated cryptococcal meningitis in South Africa?
HIV-associated cryptococcosis continues to contribute substantially to illness and death among people living with HIV in South Africa, despite important progress in expanding access to antiretroviral therapy (ART). Cryptococcosis is a serious opportunistic fungal infection caused by Cryptococcus neoformans or Cryptococcus gattii. It most commonly presents as cryptococcal meningitis but can also occur as pneumonia, fungaemia, or disseminated disease affecting multiple organs. The disease is most often seen in individuals with advanced HIV disease, particularly among those who are not yet on ART, have interrupted treatment, or experience challenges with sustained engagement in care.
Globally, cryptococcal meningitis remains an important contributor to AIDS-related mortality, with a large proportion of cases occurring in low- and middle-income countries. In response, several national interventions have been introduced to support earlier detection and improved clinical outcomes. Since 2016, reflex cryptococcal antigen screening has been implemented to identify early cryptococcal infection among individuals with low CD4 cell counts and support timely pre-emptive treatment. In addition, updated treatment guidelines incorporating flucytosine, approved by the South African Health Products Regulatory Authority, have strengthened recommended treatment regimens for cryptococcal meningitis.
Laboratory-confirmed cryptococcal disease has been monitored nationally through the GERMS-SA surveillance programme, coordinated by the National Institute for Communicable Diseases, since 2005. The following report describes national trends in HIV-associated cryptococcal meningitis and culture-confirmed cryptococcosis from 2018 to 2023, including incidence patterns, demographic characteristics, and factors associated with in-hospital mortality.
Materials and Methods
We conducted a cross-sectional analysis of the GERMS-SA nationwide laboratory-based surveillance for cryptococcosis in South Africa. To examine trends of cryptococcosis, we included all patients enrolled in GERMS-SA from 01 January 2018 to 31 December 2023. A demographic and clinical description of people with cryptococcosis was undertaken using information collected from laboratory records and through enhanced surveillance by nurse
surveillance officers at 30 public-sector sentinel hospitals, using standardised case report forms.
This analysis incorporated incident cases of laboratory-confirmed CM, fungaemia (a positive blood culture), and other culture confirmed forms of cryptococcosis.
Results
We detected 31 701 cases of cryptococcosis, of which 29 601 were incident cases. Among incident cases, CM accounted for 95% (n=28 247), followed by fungaemia (4%; n=1 208). Overall, most incident cases were diagnosed in the KwaZulu-Natal (25%, n=7 383), Gauteng (23%, n=6 691), and Eastern Cape (16%, n=4 688) provinces.
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