Leave no one behind: response to new evidence and guidelines for the management of cryptococcal meningitis in low-income and middle-income countries

Angela Loyse, Jessica Burry, Jennifer Cohn, Nathan Ford, Tom Chiller, Isabela Ribeiro, Sinata Koulla-Shiro, Janneth Mghamba, Angela Ramadhani, Rose Nyirenda, Sani H Aliyu, Douglas Wilson, Thuy Le, Rita Oladele, Sokoine Lesikari, Conrad Muzoora, Newton Kalata, Elvis Temfack, Yacouba Mapoure, Victor SiniDuncan Chanda, Meshack Shimwela, Shabir Lakhi, Jonathon Ngoma, Lilian Gondwe-Chunda, Chase Perfect, Amir Shroufi, Isabelle Andrieux-Meyer, Adrienne Chan, Charlotte Schutz, Mina Hosseinipour, Charles Van der Horst, Jeffrey D Klausner, David R Boulware, Robert Heyderman, David Lalloo, Jeremy Day, Joseph N Jarvis, Marcio Rodrigues, Shabbar Jaffar, David Denning, Chantal Migone, Megan Doherty, Olivier Lortholary, Françoise Dromer, Muirgen Stack, Síle F Molloy, Tihana Bicanic, Joep van Oosterhout, Peter Mwaba, Cecilia Kanyama, Charles Kouanfack, Sayoki Mfinanga, Nelesh Govender, Thomas S Harrison

Research output: Contribution to journalReview articlepeer-review

Abstract

In 2018, WHO issued guidelines for the diagnosis, prevention, and management of HIV-related cryptococcal disease. Two strategies are recommended to reduce the high mortality associated with HIV-related cryptococcal meningitis in low-income and middle-income countries (LMICs): optimised combination therapies for confirmed meningitis cases and cryptococcal antigen screening programmes for ambulatory people living with HIV who access care. WHO's preferred therapy for the treatment of HIV-related cryptococcal meningitis in LMICs is 1 week of amphotericin B plus flucytosine, and the alternative therapy is 2 weeks of fluconazole plus flucytosine. In the ACTA trial, 1-week (short course) amphotericin B plus flucytosine resulted in a 10-week mortality of 24% (95% CI -16 to 32) and 2 weeks of fluconazole and flucytosine resulted in a 10-week mortality of 35% (95% CI -29 to 41). However, with widely used fluconazole monotherapy, mortality because of HIV-related cryptococcal meningitis is approximately 70% in many African LMIC settings. Therefore, the potential to transform the management of HIV-related cryptococcal meningitis in resource-limited settings is substantial. Sustainable access to essential medicines, including flucytosine and amphotericin B, in LMICs is paramount and the focus of this Personal View.

Original languageEnglish
Pages (from-to)e143-e147
Number of pages5
JournalThe Lancet. Infectious diseases
Volume19
Issue number4
DOIs
Publication statusPublished - Apr 2019

Keywords

  • Africa/epidemiology
  • Amphotericin B/agonists
  • Antifungal Agents/economics
  • Coinfection
  • Cryptococcus neoformans/drug effects
  • Developing Countries
  • Disease Management
  • Drug Administration Schedule
  • Drug Therapy, Combination/economics
  • Fluconazole/economics
  • Flucytosine/economics
  • Guidelines as Topic
  • HIV Infections/mortality
  • Humans
  • Income
  • Meningitis, Cryptococcal/drug therapy
  • Survival Analysis

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