1 – Advanced HIV disease remains a significant challenge. Despite major progress over the last decade in expanding access to antiretroviral therapy (ART) and reducing HIV-related deaths, up to half of people living with HIV (PLHIV) present to care with advanced disease, and many continue to die from HIV-related opportunistic infections. We need to find better ways to identify and manage advanced HIV disease, in order to achieve the global target to reduce HIV deaths by 50% by 2020.
2 – Cryptococcal meningitis is a serious opportunistic infection and a major cause of morbidity and mortality among PLHIV with advanced disease. It is responsible for an estimated 15% of all HIV-related deaths globally – 3 quarters of which occur in sub-Saharan Africa. It is estimated that 223 100 cases of cryptococcal meningitis result in 181 000 deaths each year among PLHIV.
3 – Most people dying of cryptococcal meningitis live in low-income countries. Frequently, people are not diagnosed early enough because rapid diagnostic tests and lumbar puncture are unavailable. The first-line antifungal drugs that are used for treatment are costly and often not available to save the lives of people infected with cryptococcal meningitis. Another important factor is the limited ability of low-income countries to monitor and manage complications during treatment, including antifungal drug toxicity, raised intracranial pressure and immune reconstitution inflammatory syndrome.
4 – In March 2018, WHO is releasing updated "Guidelines on the diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents and children". These guidelines provide new or updated recommendations and good practice guidance on the following areas:
- the optimal approach to diagnose cryptococcal meningitis;
- preventing cryptococcal meningitis by screening people who have advanced HIV disease with a cryptococcal antigen test, and treating those who test positive with fluconazole;
- shorter, safer and more effective antifungal drug regimens to treat cryptococcal meningitis with a 1-week combination antifungal regimen of amphotericin B and flucytosine for the induction phase of treatment. This 1-week regimen has been shown to reduce mortality by 38%, compared to the previously recommended 2-week regimen. It is also safer and reduces the risk of anaemia (a frequent complication of antifungal drug treatment) by 69%, when compared to the previous regimen;
- ways to prevent, monitor and manage complications arising from treatment of cryptococcal meningitis, including antifungal drug toxicity;
- warnings against using systemic corticosteroids routinely in the treatment of cryptococcal meningitis; and
- the best time to start ART in people with cryptococcal meningitis.
5 – Implementation of the new WHO guidelines will help improve diagnosis, prevention and treatment of one of the most common opportunistic infections among people with advanced HIV disease. It will also reduce the rates of HIV-related mortality – globally and particularly in Africa.