Prevalence, antifungal susceptibility and etiology of vulvovaginal candidiasis in sub-Saharan Africa: a systematic review with meta-analysis and meta-regression

Vulvovaginal candidiasis (VVC) is a commonly occurring form of mucocutaneous candidiasis in women. The aim of this study was to comprehensively investigate the prevalence, antifungal susceptibility, and etiology of VVC in sub-Saharan Africa (SSA). A search of studies was conducted in seven online databases and the reference lists of selected studies. Observational studies published between January 2000, to July 2021, that met the eligibility criteria were included. Meta-analyses with random and fixed-effects model, and subgroup analyses were performed using STATA 16.0. A total of 41 studies including 15 723 participants were included in the meta-analyses. The pooled prevalence of VVC was 33% (95% Confidence Interval (CI): 28-38%, I-2 = 98%, P < 0.001). Pregnant women had 6% higher odds of having VVC compared to non-pregnant women Odds Ratio (OR): 1.06, 95% CI: 0.99-1.13, P = 0.107). The odds of diagnosing VVC were 40% higher in symptomatic patients than general study population (OR: 1.4, 95% CI: 1.3-1.5, P < 0.0001). In 17 studies, a total of 2112 isolates of Candida species were reported: 1514 (71.7%) Candida albicans, 510 (24.1%) non-albicans Candida (NAC) species and 88 (4.2%) unidentified Candida spp. Of the NAC species detected, Candida glabrata (40.9%, n = 209), Candida krusei (21.2%, n = 108), and Candida tropicalis (22.7%, n = 116) were the most common. Resistance to fluconazole in Candida albicans using disc diffusion methods ranged from 6.8% in Cameroon to 53.7% in Ethiopia. One-third of women in SSA have VVC, mainly caused by C. albicans. Data on the susceptibility of the Candida isolates to commonly used antifungal agents is limited and warrants further research. Lay Summary The overarching aim of this study was to comprehensively investigate the prevalence, antifungal susceptibility, and causative species of vulvovaginal candidiasis (VVC) in sub-Saharan Africa (SSA). A detailed search of studies was conducted to retrieve eligible observational studies published 'between' January 1, 2000, to July 31, 2021. From the 41 selected studies including 15 723 participants, VVC was found in 33% of the participants. The chances of diagnosing VVC was 40% higher in symptomatic patients compared to the general study population. In 71.7% of the cases, C. albicans was the causative species of VVC. We conclude that about one-third of women in SSA have VVC, mainly caused by C. albicans.