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Int J Infect Dis. 2017 Oct;63:57-63. doi: 10.1016/j.ijid.2017.08.004. Epub 2017 Aug 12.

Outcomes of HIV-positive patients with cryptococcal meningitis in the Americas.

Author information

1
Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Mexico City, Mexico. Electronic address: brenda.crabtree@infecto.mx.
2
Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Mexico City, Mexico.
3
Vanderbilt University School of Medicine, Nashville, TN, United States.
4
Fundación Huésped, Buenos Aires, Argentina.
5
Instituto de Pesquisa Clinica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
6
Universidad de Chile, Fundación Arriarán, Santiago, Chile.
7
Instituto Hondureño de Seguridad Social and Hospital Escuela, Tegucigalpa, Honduras.

Abstract

BACKGROUND:

Cryptococcal meningitis (CM) is associated with substantial mortality in HIV-infected patients. Optimal timing of antiretroviral therapy (ART) in persons with CM represents a clinical challenge, and the burden of CM in Latin America has not been well described. Studies suggest that early ART initiation is associated with higher mortality, but data from the Americas are scarce.

METHODS:

HIV-infected adults in care between 1985-2014 at participating sites in the Latin America (the Caribbean, Central and South America network (CCASAnet)) and the Vanderbilt Comprehensive Care Clinic (VCCC) and who had CM were included. Survival probabilities were estimated. Risk of death when initiating ART within the first 2 weeks after CM diagnosis versus initiating between 2-8 weeks was assessed using dynamic marginal structural models adjusting for site, age, sex, year of CM, CD4 count, and route of HIV transmission.

FINDINGS:

340 patients were included (Argentina 58, Brazil 138, Chile 28, Honduras 27, Mexico 34, VCCC 55) and 142 (42%) died during the observation period. Among 151 patients with CM prior to ART 56 (37%) patients died compared to 86 (45%) of 189 with CM after ART initiation (p=0.14). Patients diagnosed with CM after ART had a higher risk of death (p=0.03, log-rank test). The probability of survival was not statistically different between patients who started ART within 2 weeks of CM (7/24, 29%) vs. those initiating between 2-8 weeks (14/53, 26%) (p=0.96), potentially due to lack of power.

INTERPRETATION:

In this large Latin-American cohort, patients with CM had very high mortality rates, especially those diagnosed after ART initiation. This study reflects the overwhelming burden of CM in HIV-infected patients in Latin America.

KEYWORDS:

AIDS; AIDS defining events; Cryptococcal meningitis; HIV; Latin America; Opportunistic Infections in HIV

PMID:
28807740
PMCID:
PMC5649441
DOI:
10.1016/j.ijid.2017.08.004
[Indexed for MEDLINE]
Free PMC Article

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