Despite increased access to antiretroviral therapy, cryptococcal disease is still widespread among South African patients with HIV, investigators write in the June 1st edition of AIDS. They note that a substantial number of HIV-positive patients with very low CD4 cell counts are not accessing antiretroviral therapy, meaning that “the burden of cryptococcal meningitis is likely to continue undiminished in many areas”.
Cryptococcus is the most common cause of adult meningitis in most of southern and eastern Africa. Despite the availability of anti-fungal treatment, mortality ranges between 20% and 50%.
Earlier research has shown that between 10% and 20% of all deaths in HIV-positive individuals in southern Africa are due to cryptococcus.
Investigators monitored the number of cases of cryptococcal meningitis diagnosed at the GF Jooste Hospital in Cape Town, South Africa between 2003 and 2008. This hospital serves an adult population of 1.3 million. The estimated local HIV prevalence in 2006 was 33%.
Access to antiretroviral treatment has expanded significantly for the hospital’s patients. In 2003 only 660 individuals were receiving HIV treatment, but this had increased to almost 14,000 at the end of 2008. Across South Africa, it is estimated that 60% of patients with AIDS are now accessing HIV treatment.
However, despite these gains in the availability of HIV treatment, the absolute number of patients with advanced HIV disease who are not accessing antiretroviral therapy has not fallen.
In line with this finding, the investigators report that there has been no significant change in the number of case of cryptococcal disease diagnosed in HIV-positive patients attending their hospital.
In 2003, 80 cases of this infection were diagnosed, with over 100 diagnosed in 2008.
“Despite implementation of successful treatment programmes, in many settings, the numbers of people progressing to advanced immunosuppression exceeds the capacity of antiretroviral programmes”, write the investigators. They add, “large numbers of patients presenting to health services with advanced HIV and opportunistic infections die without accessing antiretroviral therapy".
They believe that their analysis shows that there is an urgent need to improve the management of cryptococcal meningitis in patients with HIV “and to facilitate earlier diagnosis and treatment, especially now that access to antiretroviral therapy offers the possibility of a good long-term prognosis, provided that patients survive the acute cryptococcal inection. This needs to be specifically addressed as an integral part of the response to the HIV epidemic in Africa, along with earlier HIV diagnosis and access to antiretrovirals.”
Jarvis JN et al. High ongoing burden of cryptococcal disease in Africa despite antiretroviral roll out. AIDS 23: 1182, 2009.