The epidemiology and clinical features of HIV and Trypanosoma cruzi (Chagas disease) co-infection: A systematic review and individual patient data analysis

BACKGROUND: Narrative descriptions of HIV and Trypanosoma cruzi, the causative agent of Chagas disease, co-infection exist in the literature but the breadth and depth of the data underlying these descriptions has not been previously thoroughly scrutinised and reactivation is poorly understood. The aim of this systematic review was to identify, synthesise and analyse the published literature on the epidemiology and clinical features of T. cruzi and HIV co-infection. METHODS: A systematic review of published literature on HIV and T. cruzi co-infection was conducted. Six international databases were searched: Medline, Embase, Global Health, Global Index Medicus (including LILACS, AIM, IMEMR, IMSEAR & WPRIM), Web of Science and Scopus. Articles reporting on HIV and T. cruzi co-infection, as defined by the authors, with no restrictions on study type, language or date of publication or reporting were included. RESULTS: 152 articles (62% case reports or series) were included, of which 110 reported individual patient data on 352 individuals with HIV and T. cruzi co-infection. Reported prevalence of co-infection varied by region and setting of screening, ranging from 0.2% to 5%. 86% of reactivations were reported in individuals with CD4 < 200 cells/mm3. CNS reactivation, typically presenting with meningoencephalitis and/or central nervous system (CNS) lesions, accounted for 85% of all published cases of reactivation. Myocarditis (accounting for 10% published reactivation cases) was less well characterised. Mortality of all reactivation cases was 67% (79% in those with CNS reactivation). CONCLUSION: T. cruzi reactivation mainly affects those with untreated HIV and lower CD4 counts. CNS reactivation is the most common clinical picture and confers high mortality. Prompt recognition of reactivation and immediate initiation of trypanocidal therapy (with benznidazole or nifurtimox) is recommended. Increased education and better awareness of the risks of co-infection are needed, as is systematic screening of individuals at-risk. TRIAL REGISTRATION: Prospero CRD42020216125.