Revue Malgache de Biologie Clinique (2) 2025 : 029-34

ORIGINAL RESEARCH

Infections opportunistes  associées au statut immunitaire des personnes infectées par VIH à Madagascar : les candidoses muqueuses ?

Opportunistic infections and immune status of HIV infected patients in Madagascar:  mucosal candidiasis?

Revue Malgache de Biologie Clinique (2) 2025 : 029-34

EE BATAVISOANIATSY¹, N RANOROHASIMANANA¹, SA HARINIAINA¹, A ANDRIANIAINA², MJD RANDRIA², AL RAKOTOVAO², RT RANDRIAMAHAZO¹

1. Laboratory of Immunology and Molecular Biology ? Joseph Ravoahangy Andrianavalona University Hospital Center, Faculty of Medicine of Antananarivo

2. Infectious Diseases Unit, University Hospital Joseph Raseta Befelatanana, University Hospital of Antananarivo, Antananarivo, Madagascar,

Auteur correspondant :

BATAVISOANIATSY Elodie Emile

E-mail : elodie.kwely@gmail.com

Téléphone : +261 34 66 411 55

RESUME

Introduction : Les infections opportunistes dont les candidoses compromettent la prise en charge de l’infection rétrovirale. Leur apparition est associée à l’état immunitaire du patient. L’objectif de l’étude a été de déterminer la prévalence des candidoses orales et urinaires chez les PVVIH à Madagascar selon leur taux de lymphocytes CD4+ (LTCD4+).

Méthodologie : Une étude prospective descriptive de 01 an a été menée de Janvier 2020 à Janvier 2021 dans 02 centres hospitaliers universitaires d’Antananarivo. Ont été inclus les PVVIH hospitalisés, sous traitement antirétroviral, ayant consenti à participer à l’étude. Les paramètres démographiques ainsi que les facteurs de risque cliniques ont été évalués. Le taux de LTCD4+ a été effectué sur l’appareil FACS Presto™  de Beckton Dickinson. La culture mycologique a été faite sur milieu Sabouraud suivie d’identification. Le test de corrélation a été évalué sur Epi Info 7.0.

Résultats : Cent (100) PVVIH ont été incluses. La prévalence des candidoses a été de 62% avec 50 cas de candidoses orales et 12 cas de candidoses urinaires. Le sex ratio a été de 6,14 pour les candidoses orales et 5,0 pour les candidoses urinaires avec une prédominance de la tranche d’âge de 20-30 ans. Un taux de CD4 compris entre 200 et 600 cellules/mm³ a été retrouvé chez 66% des candidoses urinaires (n=8), tandis qu’un taux inférieur à 200 cellules/mm³ est significativement associé à l’apparition des candidoses orales.

Conclusion : Les candidoses orales et urinaires sont fréquentes chez les PVVIH Malagasy sous traitement ARV. Elles sont associées au taux de CD4+ des patients. Une détection précoce de ces infections nécessite la mise en place des plateaux techniques adéquats.

SUMMARY

Introduction:

Opportunistic infections such as candidiasis compromise the management of retroviral infection. Their onset is associated with the patient's immune status.  The aim of the study was to determine the prevalence of oral and urinary candidiasis in PLHIV in Madagascar according to their CD4+ lymphocyte count (LTCD4+).

Methodology:

A one-year prospective descriptive study was conducted from January 2020 to January 2021 in two university hospitals in Antananarivo. The study included PLHIV who were hospitalized, receiving antiretroviral treatment, and who consented to participate in the study. Demographic parameters and clinical risk factors were assessed. The LTCD4+ count was performed on the Beckton Dickinson FACS Presto™ device. Mycological culture was performed on Sabouraud medium followed by identification. The correlation test was evaluated on Epi Info 7.0.

Results:

One hundred (100) PLHIV were included. The prevalence of candidiasis was 62% with 50 cases of oral candidiasis and 12 cases of urinary candidiasis. The sex ratio was 6.14 for oral candidiasis and 5.0 for urinary candidiasis, with a predominance in the 20-30 age group. A CD4 count between 200 and 600 cells/mm3 was found in 66% of urinary candidiasis cases (n=8), while a count below 200 cells/mm3 is significantly associated with the onset of oral candidiasis.

Conclusion:

Oral and urinary candidiasis are common among Malagasy PLHIV undergoing ARV treatment. They are associated with patients' CD4+ counts. Early detection of these infections requires the establishment of adequate technical platforms.

INTRODUCTION

People living with HIV (PLHIV) are prone to complications and comorbidities, including opportunistic infections (1). Despite the widespread use of antiretroviral therapy (ART), these opportunistic infections remain prevalent. The main comorbidities associated with HIV infection are candidiasis, tuberculosis, pneumocystosis, toxoplasmosis, herpes, Kaposi's sarcoma, cryptococcosis, and protozoal infections (2).

The overall prevalence of HIV infection in Madagascar remains low compared to other sub-Saharan countries. In 2016, it was 0.2% among adults aged 15-49, with 4,300 new cases in the same year (3). Since 2005, access to ARV treatment for PLHIV in the country has been adopted without taking into account their CD4+ T-cell count (CD4+ LT), in accordance with WHO recommendations. However, opportunistic infections are the most common reason for admission of PLHIV to university hospitals. The main pathology recorded in this context is tuberculosis (3). Fungal infections such as mucosal candidiasis remain poorly evaluated, including in Madagascar. 

Worldwide, oropharyngeal and urinary candidiasis have been increasingly reported among PLHIV . Oral candidiasis is the most common opportunistic infection of the oral cavity in PLVIH (4). It is a fungal infection caused by Candida sp, the most common species being Candida albicans. Various risk factors contribute to this infection, including age, gender, xerostomia, smoking, alcohol, increased use of antibiotics, oral hygiene, clinical stage of the disease, and CD4 count (5). Candiduria, on the other hand, represents a high risk of morbidity in PLHIV. Indeed, it can develop into systemic candidiasis. However, no clear criteria for distinguishing between colonization and Candida infection in the urinary tract have been established (6).

The aim of the study is to determine the prevalence of these Candida infections in PLHIV in Madagascar according to their LTCD4+ count.

MATERIALS AND METHODS

A prospective descriptive and analytical study was conducted from January 2020 to January 2021 in Antananarivo. Patient recruitment was carried out at the Infectious Diseases Department of the Joseph Raseta Befelatanana University Hospital Center (CHUJRB). Biological analyses were performed at the Immunology and Molecular Biology Laboratory and the Parasitology-Mycology Laboratory of the Joseph Ravoahangy Andrianavalona University Hospital Center (CHU-JRA).  All people living with HIV (PLHIV) on antiretroviral treatment admitted to the hospital during this period were included in the study. Those who had received local or systemic antifungal treatment within the previous month were excluded.

Each patient's participation in the study was granted after signing an informed consent form, preceded by an explanation of the study by the investigator on site, in accordance with the guidelines of the Declaration of Helsinki. The data were recorded anonymously. A questionnaire on epidemiological and clinical parameters was completed for each patient, including age, gender, risk factors for urinary tract infection (diabetes, smoking, urinary catheterization), and symptoms suggestive of oral and/or urinary candidiasis.

Laboratory tests included determination of CD4+ T lymphocyte (CD4+ LT) levels and mycological examination of urinary and oral samples. CD4+ LT levels were measured using the Beckton Dickinson FACS Presto™ portable device on whole blood collected in an EDTA tube. This sample was taken at the same time as the oral and urinary samples for candidiasis testing. For mycological samples, the genital area was cleaned prior to urine collection. Urine was collected from the middle of the morning urine stream in a sterile bottle. The oral sample was collected by swabbing the oral mucosa in the morning after rinsing the mouth with water. One swab per patient was used.

The mycological study involved inoculation on Sabouraud Chloramphenicol medium: 10µl for urine samples and direct inoculation using swabs for oral samples. Incubation took place at 37°C for 24-48 hours. Candida spp. colonies appear whitish, creamy, smooth, and shiny. A significance threshold of ≥10³ CFU/ml was used for urinary candidiasis caused by Candida spp. For oral candidiasis, cultures with more than 10² CFU/ml were considered positive. The blastocyst test was used to identify Candida albicans and the filamentation test to identify the presence of germ tubes.

The data were entered into Excel and analyzed using Epi Info. The correlation between CD4+ LT counts and the prevalence of candidiasis was evaluated using Student's t-test and the Chi-square test.

RESULTS

One hundred (100) PLHIV were enrolled. Mucosal candidiasis was recorded in 62 individuals, including 50 cases of oral candidiasis and 12 cases of urinary candidiasis. No cases of dual localization were recorded.

Tuberculosis infection was present in 66% of PLHIV with oral candidiasis (n=33) and in 75% of those with urinary candidiasis (n=9).  

For oral candidiasis, men were the most affected with 86% of cases (n=43) compared to 14% in women (n=7). The characteristics of the PLHIV population with mucosal candidiasis are described in Table I.

A CD4 count <200 cells/mm3 was found in 46% of patients (n=23) with oral candidiasis. There was a significant statistical correlation between CD4 count and the presence of oral candidiasis (p = 0.01). The species Candida albicans was isolated in 36 patients with oral candidiasis, or 72%.

Twelve (12) cases of urinary candidiasis were recorded, including 9 cases with tuberculosis co-infection, or 75%, and 3 cases without tuberculosis (25%). Men were the most affected (83%; n=9). A CD4 count between 200 and 600 cells/mm3 was recorded in 66% of cases of urinary candidiasis (n=8). The Candida non-albicans species was identified in 75% of positive cultures.   (Table I).

Table I: Characteristics of HIV-positive people with mucosal candidiasis

DISCUSSION

Candida sp. colonizes the skin and mucous membranes. It normally exists on the surface of the mucous membranes and becomes pathogenic under certain conditions or predisposing factors (1). The incidence of candidiasis increases with age, affecting 60% of people over 60 years of age. Candida sp infection is common in PLHIV (7). The prevalence of oral fungal infections has increased recently, linked to the increased use of antibiotics and immunodeficiencies, including HIV infection (8).

The PLHIV included in our observation were predominantly young. The 20-30 age group was the majority among both PLHIV with oral candidiasis (42%; n=21) and PLHIV with candiduria (50%; n=6). These data are consistent with the young profile of PLHIV in Antananarivo in 2019, with a median age of 33 years [range 27-41] (9). Similarly, the average age of PLHIV were 35.95 ±8.92 years and  39.39 ± 11 years in Indonesia (10) and in Cameroon (11), respectively whereas the peak age for HIV infection was in the thirties in India  (12). In Indonesia, being over 34 years of age is statistically associated with the onset of oral candidiasis in PLHIV. (10).  According to Takahashi et al, the risk of developing oral candidiasis among PLHIV in the Japanese population is statistically associated with age [p= 0.007; OR=1.02; 95% CI= 1.00–1.03] (13).

A male predominance was found among PLHIV with tuberculosis co-infection seen in the laboratory during the study period.  In Madagascar, Raberahona et al. already reported this male predominance in 2018, with 63.6% of men among PLHIV hospitalized at the CHU-JRB(3). In Indonesia, being male is significantly associated with a high risk of developing oral candidiasis among PLHIV (p=0.002) (10). Likewise,  in India, oral candidiasis affects 18.8% of men compared to 10.3% of women living with HIV (p=0.000) (1).  In Africa, however, it is mainly women living with HIV who are at risk of candidiasis, particularly digestive candidiasis. In Nigeria in 2017, Awoyeni et al reported that 90.2% of PLHIV with digestive candidiasis were women (n=55/61) (14). Moreover, being female is a major risk factor in this country (12).

Fifty (50) cases of oral candidiasis were isolated, 86% of which were male and 21% of which were under the age of 30. Their LTCD4+ rate was above 600 cells/mm3 in only 14% of cases (n=7). Oral candidiasis is known to be a marker of the immunological stage of PLHIV. (15). It is one of the seven main lesions associated with HIV infection, along with gingivitis and necrotizing ulcerative periodontitis, linear gingival erythema, villous leukoplakia, Kaposi's sarcoma, and non-Hodgkin's lymphoma (7).

A significant statistical correlation was found between CD4 count and the presence of oral candidiasis (p = 0.01) in our observation. Suryana K et al reported that a CD4+ count below 108 cells/mm3 would increase the risk of oral candidiasis threefold (p=0.000, OR= 3.29) (10). In India, oral candidiasis was significantly correlated with a CD4+ count below 200 cells/mm3 (p=0.000, OR=3.1 (8)). In Africa, a significant association was reported between oral candidiasis and a CD4+ count below 350 cells/mm3 in Cameroonian PLHIV (p<0.001, OR= 2.69; CI=95%), (16).    The onset of oral candidiasis is associated with a CD4+ T-cell count below 200 cells/mm3, but also with a viral load above 103 copies/ml and clinical progression of the disease (13). This is thought to be due to a weakened immune system (17). Viral load could not be determined for our patients at the time of recruitment.

CD4+ count and HIV viral load testing are part of the biological monitoring of PLHIV in Madagascar. Only a few centers are equipped to perform these tests. The use of the portable device in our study could be a positive approach. Indeed, a CD4+ count below 200 cells/mm3 was only a risk factor in PLHIV who were not on ARV treatment (p= 0.0001, OR= 11.71, CI=95%) (18). In the absence of CD4+ testing in PLHIV, the presence of oral candidiasis lesions suggests severe immunosuppression and should prompt initiation of ARV treatment.  In the present study, a high rate of oral candidiasis However, the absence of oral candidiasis does not rule out advanced immunosuppression. This finding is useful in places where LTCD4+ testing is not available (19).

Mycological examination of urine isolated 12 cases of candiduria in PLHIV (12%) seen in the laboratory, mainly affecting men (83%) and the 20-30 age group in 50% of cases. In Nigeria, 13.5% of candiduria cases were isolated in PLHIV. In Brazil, the prevalence is 22% among hospitalized PLHIV. Candiduria accounts for 10% of urinary tract infections in PLHIV (20).

HIV status is significantly associated with candiduria (OR= 3.746; CI= 95%) (6).  In Cameroon, the prevalence of candiduria was 18.8–36.2% in two different locations, with 37% of cases caused by C. albicans and 63% by non-albicans species (11). However, Cameroonian women were the most exposed to candiduria, accounting for 79% of cases. This could be explained by the anatomical structure of the female genitourinary tract. In Nigeria, the same observation has been made, suggesting that being female is a risk factor for candiduria. This may also be linked to the role of hormones such as estrogen and progesterone, which are found in lower levels in men (18). Risk factors for candiduria include immunosuppression, broad-spectrum antibiotic therapy, gender, age, diabetes, renal failure, cancer, urological malformations, pregnancy, and neutropenia. We were unable to evaluate other risk factors in our study. The predominance of candiduria in men in our population could be explained by the high proportion of men among PLHIV throughout Madagascar.

Due to a lack of resources, our study was only able to identify Candida albicans and Candida non-albicans species. C. albicans has long been the predominant species in oropharyngeal candidiasis. However, non-albicans species are increasingly emerging as the main opportunistic pathogens. Non-albicans species include: C. glabrata, C. parapsilosis, C. tropicalis, and C. krusei. The species C. glabrata is often isolated in the oral cavity in co-infection with C. albicans or in isolation (21). In Nigeria, the species recorded were C. albicans (88.57%), C. krusei (8.57%) and C. parapsilosis (2.86%). There is a significant correlation between candiduria and ARV treatment and CD4+ counts (20).

CONCLUSION

Despite the introduction of ARV treatment for PLHIV in Madagascar, opportunistic infections remain a major problem in their care. In addition to tuberculosis, the prevalence of candidiasis among PLHIV in Madagascar was 62%, with 50 cases of oral candidiasis and 12 cases of candiduria. The infection mainly affects men and particularly the 20-30 age group. The incidence of Candida infections remains low among PLHIV with CD4+ counts above 600 cells/mm3. Early detection of these opportunistic infections through the establishment of technical platforms for mycological identification, HIV viral load, and CD4+ count measurement in our hospitals would represent a step forward in the care of PLHIV in Madagascar.

Declaration of interests

We declare no competing interests

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