Leave no one behind: response to new evidence and guidelines for the management of cryptococcal meningitis in low-income and middle-income countries.
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.
Loyse, A; Burry, J; Cohn, J; Ford, N; Chiller, T; Ribeiro, I; Koulla-Shiro, S; Mghamba, J; Ramadhani, A; Nyirenda, R; Aliyu, SH; Wilson, D; Le, T; Oladele, R; Lesikari, S; Muzoora, C; Kalata, N; Temfack, E; Mapoure, Y; Sini, V; Chanda, D; Shimwela, M; Lakhi, S; Ngoma, J; Gondwe-Chunda, L; Perfect, C; Shroufi, A; Andrieux-Meyer, I; Chan, A; Schutz, C; Hosseinipour, M; Van der Horst, C; Klausner, JD; Boulware, DR; Heyderman, R; Lalloo, D; Day, J; Jarvis, JN; Rodrigues, M; Jaffar, S; Denning, D; Migone, C; Doherty, M; Lortholary, O; Dromer, F; Stack, M; Molloy, SF; Bicanic, T; van Oosterhout, J; Mwaba, P; Kanyama, C; Kouanfack, C; Mfinanga, S; Govender, N; Harrison, TS
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