New study explores global inequities in meningitis diagnosis, treatment, and mortality among people living with HIV

Cryptococcal meningitis (CM) is not uncommon among people living with HIV (PLWH), but incidence and mortality rates, as well as access to diagnosis and treatment, vary considerably across the world, according to a newly published study. In many resource-poor countries, standard treatment was found to be lacking—and the efficacy of available HIV treatment options may also contribute.

About This Study

“Cryptococcal Meningitis and Clinical Outcomes in Persons with HIV: A Global View” was published online on Feb. 23, 2023, in Clinical Infectious Diseases. The lead author is Anna K. Person, M.D., of the Division of Infectious Diseases at Vanderbilt University Medical Center in Nashville, Tennessee.

Key Research Findings

This retrospective cohort study looked at CM incidence and treatment availability in PLWH worldwide.

Data came from 518,852 participants in the International Epidemiology Databases to Evaluate AIDS cohort from 1996-2017. Participants were followed for a median of 3.4 years from the time they were enrolled in the study.

A total of 3,857 CM diagnoses were reported, at a mortality rate of 32%, with 29% of participants lost to follow-up after diagnosis. Sixty-four percent of diagnoses occurred after starting antiretroviral treatment (ART), but many PLWH had high viral loads at that point, indicating treatment failure. CM incidence dropped over time, from 2.56/1,000 person-years in 2005 to 0.97/1,000 person-years in 2015. Mortality was higher among older participants, those with low CD4 counts, and PLWH diagnosed with CM early in the study period.

“Gold standard” treatment of CM with 5-flucytosine was available at only 12% of sites. CM medications recommended by the World Health Organization at the time, such as fluconazole, were not accessible at 8% of sites. Meningitis testing was also not available everywhere: 53% of sites could perform serum antigen tests and 37% could use lateral flow assays.

Discussion Highlights and Implications for Practice

The heterogeneity of study sites and their data collection practices, and the retrospective nature of the study, introduced major limitations, the study authors said. However, the basic findings remain: CM diagnoses were not uncommon but declined over time; mortality from the condition was high in some regions; and CM treatment availability was limited in many low- and middle-income countries.

The authors believe these inequities in access to CM testing and treatment may explain some of the high mortality rate. Another factor is HIV treatment failure at the time of CM diagnosis, indicating that better HIV care management may prevent CM. Study authors called for additional research into CM diagnostic modalities and treatment regimens that may be better accessible in resource-poor regions.

By Barbara Jungwirth