Antiretroviral roll-out, antifungal roll-back: access to treatment for cryptococcal meningitis

Abstract

Cryptococcal meningitis is a common and often fatal opportunistic infection in patients with late stage HIV infection especially in Africa and Asia. US and UK guidelines for treatment recommend a combination of amphotericin B and flucytosine for the initial 2 weeks based on the results of a large randomised trial. The superior mycological efficacy of this combination has recently been confirmed in Thailand. In centres without facilities for blood monitoring amphotericin B-based therapy cannot be given safely and fluconazole is the only option. However fluconazole—an essentially fungistatic drug—takes much longer to sterilise the cerebrospinal fluid and has been associated with poorer clinical outcome compared with amphotericin B-based induction therapy. Moreover expanding access to antiretroviral drugs offers patients with HIV-associated cryptococcal meningitis the prospect of a good long-term prognosis provided they survive the acute cryptococcal infection supporting an aggressive approach to initial antifungal therapy. Unfortunately although access to antiretroviral drugs is increasing access to amphotericin B and flucytosine in areas with the highest burden of cryptococcal disease has been in decline. (excerpt)