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      Prevalence of Cryptosporidium, microsporidia and Isospora infection in HIV-infected people: a global systematic review and meta-analysis

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          Diarrhea caused by opportunistic intestinal protozoa is a common problem in HIV infection. We aimed to establish the prevalence of Cryptosporidium, misrosporidia, and Isospora in HIV-infected people using a systematic review and meta-analysis, which is central to developing public policy and clinical services.


          We searched PubMed, ScienceDirect, Google Scholar, Embase, Chinese Web of Knowledge, Wanfang, and Chongqing VIP databases for studies reporting Cryptosporidium, microsporidia, or Isospora infection in HIV-infected people. We extracted the numbers of people with HIV and protozoa infection, and estimated the pooled prevalence of parasite infection by a random effects model.


          Our research identified 131 studies that reported Cryptosporidium, microsporidia, and Isospora infection in HIV-infected people. We estimated the pooled prevalence to be 14.0% (3283/43,218; 95% CI: 13.0–15.0%) for Cryptosporidium, 11.8% (1090/18,006; 95% CI: 10.1–13.4%) for microsporidia, and 2.5% (788/105,922; 95% CI: 2.1–2.9%) for Isospora. A low prevalence of microsporidia and Isospora infection was found in high-income countries, and a high prevalence of Cryptosporidium and Isospora infection was found in sub-Saharan Africa. We also detected a high prevalence of Cryptosporidium, microsporidia, and Isospora infection in patients with diarrhea. Sensitivity analysis showed that three studies significantly affect the prevalence of Isospora, which was adjusted to 5.0% (469/8570; 95% CI: 4.1–5.9%) by excluding these studies.


          Our findings suggest that HIV-infected people have a high prevalence of Cryptosporidium, microsporidia, and Isospora infection in low-income countries and patients with diarrhea, especially in sub-Saharan Africa, reinforcing the importance of routine surveillance for opportunistic intestinal protozoa in HIV-infected people.

          Electronic supplementary material

          The online version of this article (10.1186/s13071-017-2558-x) contains supplementary material, which is available to authorized users.

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          Most cited references 137

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          Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.

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            Grading quality of evidence and strength of recommendations.

            Users of clinical practice guidelines and other recommendations need to know how much confidence they can place in the recommendations. Systematic and explicit methods of making judgments can reduce errors and improve communication. We have developed a system for grading the quality of evidence and the strength of recommendations that can be applied across a wide range of interventions and contexts. In this article we present a summary of our approach from the perspective of a guideline user. Judgments about the strength of a recommendation require consideration of the balance between benefits and harms, the quality of the evidence, translation of the evidence into specific circumstances, and the certainty of the baseline risk. It is also important to consider costs (resource utilisation) before making a recommendation. Inconsistencies among systems for grading the quality of evidence and the strength of recommendations reduce their potential to facilitate critical appraisal and improve communication of these judgments. Our system for guiding these complex judgments balances the need for simplicity with the need for full and transparent consideration of all important issues.
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              Zoonotic Cryptosporidium species and Enterocytozoon bieneusi genotypes in HIV-positive patients on antiretroviral therapy.

              Molecular diagnostic tools have been used increasingly in the characterization of the transmission of cryptosporidiosis and microsporidiosis in developing countries. However, few studies have examined the distribution of Cryptosporidium species and Enterocytozoon bieneusi genotypes in AIDS patients receiving antiretroviral therapy. In the present study, 683 HIV-positive patients in the National Free Antiretroviral Therapy Program in China and 683 matched HIV-negative controls were enrolled. Cryptosporidium species and subtypes and Enterocytozoon bieneusi genotypes were detected and differentiated by PCR and DNA sequencing. The infection rates were 1.5% and 0.15% for Cryptosporidium and 5.7% and 4.2% for E. bieneusi in HIV-positive and HIV-negative participants, respectively. The majority (8/11) of Cryptosporidium cases were infections by zoonotic species, including Cryptosporidium meleagridis (5), Cryptosporidium parvum (2), and Cryptosporidium suis (1). Prevalent E. bieneusi genotypes detected, including EbpC (39), D (12), and type IV (7), were also potentially zoonotic. The common occurrence of EbpC was a feature of E. bieneusi transmission not seen in other areas. Contact with animals was a risk factor for both cryptosporidiosis and microsporidiosis. The results suggest that zoonotic transmission was significant in the epidemiology of both diseases in rural AIDS patients in China.

                Author and article information

                Parasit Vectors
                Parasit Vectors
                Parasites & Vectors
                BioMed Central (London )
                9 January 2018
                9 January 2018
                : 11
                [1 ]ISNI 0000 0001 0018 8988, GRID grid.454892.6, State Key Laboratory of Veterinary Etiological Biology, Key Laboratory of Veterinary Parasitology of Gansu Province, , Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Sciences, ; Lanzhou, Gansu Province 730046 People’s Republic of China
                [2 ]ISNI 0000 0004 1803 4911, GRID grid.410740.6, Military Veterinary Institute, Key Laboratory of Jilin Province for Zoonosis Prevention and Control, , Academy of Military Medical Sciences, ; Changchun, Jilin Province 130122 People’s Republic of China
                [3 ]ISNI 0000 0000 9888 756X, GRID grid.464353.3, College of Animal Science and Technology, , Jilin Agricultural University, ; Changchun, Jilin Province 130188 People’s Republic of China
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

                Funded by: National Natural Science Foundation of China
                Award ID: 31672542
                Award Recipient :
                Funded by: the Fundamental Research Funds of Chinese Academy of Agricultural Sciences
                Award ID: Y2016JC05, 1610312017004
                Award Recipient :
                Funded by: the Agricultural Science and Technology Innovation Program
                Award ID: CAAS-ASTIP-2014-LVRI-03
                Award Recipient :
                Funded by: the National Key Research and Development Program of China
                Award ID: 2017YFD0501300
                Award Recipient :
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                © The Author(s) 2018


                hiv, cryptosporidium, microsporidia, isospora, meta-analysis


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