Burden of pneumocystis pneumonia in HIV-infected adults in sub-Saharan Africa: A systematic review and meta-analysis

BACKGROUND: Seroprevalence data and clinical studies in children suggest that the burden of pneumocystis pneumonia (PCP) in Africa may be underestimated. We performed a systematic review to determine the prevalence and attributable mortality of PCP amongst HIV-infected adults in sub-Saharan Africa. METHODS: We searched Pubmed, Web of Science, Africa-Wide: NiPAD and CINAHL, from Jan 1 1995 to June 1 2015, for studies that reported the prevalence, mortality or case fatality of PCP in HIV-infected adults living in sub-Saharan African countries. Prevalence data from individual studies were combined by random-effects meta-analysis according to the Mantel-Haenszel method. Data were stratified by clinical setting, diagnostic method, and study year. RESULTS: We included 48 unique study populations comprising 6884 individuals from 18 countries in sub-Saharan Africa. The pooled prevalence of PCP among 6018 patients from all clinical settings was 15.4% (95% CI 12.9–18.0), and was highest amongst inpatients, 22.4% (95% CI 17.2–27.7). More cases were identified by bronchoalveolar lavage, 21.0% (15.0–27.0), compared with expectorated, 7.7% (4.4–11.1), or induced sputum, 11.7% (4.9–18.4). Polymerase chain reaction (PCR) was used in 14 studies (n=1686). There was a trend of decreasing PCP prevalence amongst inpatients over time, from 28% (21–34) in the 1990s to 9% (8–10) after 2005. The case fatality rate was 18.8% (11.0–26.5), and PCP accounted for 6.5% (3.7–9.3) of study deaths. CONCLUSIONS: PCP is an important opportunistic infection amongst HIV-infected adults in sub-Saharan Africa, particularly amongst patients admitted to hospital. Although prevalence appears to be decreasing, improved access to antiretroviral therapy and non-invasive diagnostics, such as PCR, are needed.

• Population(s)
  • General HIV+ population