# Challenges in diagnosing cryptococcosis among HIV-infected patients in southern Mozambique and opportunities for intervention in contexts of limited resources: A pre-implementation study

## TL;DR

This study explores challenges in diagnosing cryptococcosis in HIV-infected patients in Mozambique and identifies opportunities for using a low-cost alternative diagnostic method.

## Contribution

The study identifies practical barriers and facilitators for reintroducing India ink microscopy as a low-cost diagnostic tool in resource-limited settings.

## Key findings

- Frequent shortages of rapid diagnostic tests and antifungal medications hinder cryptococcosis diagnosis and treatment.
- Healthcare workers recognize the need for screening and are willing to collaborate for implementing alternative diagnostic methods.
- Microscopes are universally available, making India ink microscopy a feasible low-cost alternative in the region.

## Abstract

Worldwide, cryptococcosis has increased due to HIV/AIDS, particularly in sub-Saharan Africa (SSA), where the mortality is high. Laboratory diagnosis for cryptococcosis among HIV-infected patients remains a challenge in most SSA countries. This study aimed to explore facilitators, barriers to re-implementing the India ink test, and logistical factors that could support the successful rollout of this alternative diagnostic method in southern Mozambique.

We conducted a cross-sectional study using mixed methods approaches in six hospitals across southern Mozambique over three months. Clinicians and laboratory technicians were asked to complete a questionnaire aimed to capture sociodemographic data, as well as current practices and clinical approaches with respect to cryptococcal diagnosis and clinical management. Subsequently, individual in-depth interviews were conducted to understand current challenges in the diagnosis of cryptococcosis and to assess facilitators, barriers, and potential opportunities for interventions. Quantitative data were captured through REDCap and subsequently analyzed using SPSS statistical program, while qualitative data were analyzed manually using a combination of content and thematic analysis approaches.

A total of 98 healthcare providers (67 clinicians and 31 laboratory technicians) participated in the study. The mean age of the participants was 35 years. More than half were female (58.2%) and had at least five years of relevant work experience (53.1%). Challenges in diagnosing and managing cryptococcal disease were mainly related to 1) frequent shortages in the stocks of cryptococcal rapid antigen test, 2) contextual challenges in collecting cerebrospinal fluid samples, and 3) frequent shortages in the stocks of antifungal medications. In contrast, all study facilities had availability of microscopes, recognized the need for cryptococcal screening services, and had clinicians and laboratory technicians willing to collaborate for eventual roll-out of the test as routine practice.

Frequent stock-outs of rapid diagnostic tests and challenges associated with performing lumbar punctures are barriers to routine screening for cryptococcosis. In contrast, we have identified the universal availability of microscopes and health workers’ recognition of the problem, as well as their willingness to collaborate, as potential facilitators to leverage for the successful reintroduction of India ink microscopy of urine samples as a low-cost laboratory test alternative.