New guidance on cryptococcal meningitis aims to reduce AIDS-related deaths

The World Health Organization (WHO) is releasing new treatment guidelines to address the high rate of death and disability caused by cryptococcal meningitis among people with advanced HIV in sub-Saharan Africa.

What are the guidelines about?

Treatment for cryptococcal meningitis. This is one of the most significant opportunistic infections among people with advanced HIV. It is the second leading cause of AIDS-related death worldwide, and it is also a major cause of disability. Most people with HIV who die due to cryptococcal meningitis live in sub-Saharan Africa.

Why are the guidelines important?

Many people with HIV in sub-Saharan Africa are still not on effective treatment. This means they are at risk of developing advanced HIV and then AIDS. In places where there are a lot of people with advanced HIV, the rate of cryptococcal meningitis is high, and a lot of people are dying.

One of the reasons the death-rate from cryptococcal meningitis is so high is the toxic effects of conventional treatment. It is estimated that one in two people with HIV on conventional treatment for cryptococcal meningitis will die.

In 2018, WHO updated its guidelines to recommend a more effective and less toxic treatment for cryptococcal meningitis. But even this has been linked with severe illness.

Now WHO has updated its recommendations again. If the guidelines are implemented, people with HIV who develop cryptococcal meningitis will be less at risk of death, disability and served illness.

What do the guidelines say?

The guidelines recommend giving a single high dose of liposomal amphotericin B on the first day of treating cryptococcal meningitis in someone with HIV. This should be accompanied by 14-days of two medications called flucytosine and fluconazole. Because liposomal amphotericin B can be given as a single dose it is less likely to cause toxic effects.

This new recommendation is based on the results of a randomised controlled trial in Botswana, Malawi, South Africa, Uganda and Zimbabwe. This showed that treatment with liposomal amphotericin B is as effective as the previous WHO standard of care.

Healthcare providers also preferred this new treatment. It took less time to prepare, required less monitoring, and could shorten someone's stay in hospital.

What does this mean for HIV services?

Where possible, people with HIV who develop cryptococcal meningitis should be given the single high-dose regimen instead of standard treatment.

The new guidelines will only save lives if efforts are made to improve access to liposomal amphotericin B. At the moment, only a few suppliers of this drug have received regulatory approval. Although a pricing agreement has been agreed with the manufacturer of the original drug formula, not many low- and middle-income countries have bought the medication.

If you are involved with advocacy to protect and improve the health of people with HIV this could be a subject worth exploring. You could start by seeing whether your healthcare system is planning to make liposomal amphotericin available.

WHO’s 2022 Guidelines for Diagnosing, Preventing and Managing Cryptococcal Disease are available here.