title: Long term 5-year survival of persons with cryptococcal meningitis or asymptomatic subclinical antigenemia in Uganda.
abstract: Data presented previously as an abstract at the 2011 CUGH Global Health Conference in Montreal, Canada on 15 Nov 2011. The long-term survival of HIV-infected persons with symptomatic cryptococcal meningitis and asymptomatic, subclinical cryptococcal antigenemia (CRAG+) is unknown. We prospectively enrolled 25 asymptomatic, antiretroviral therapy (ART)-naïve CRAG+ Ugandans with CD4<100 cells/mcL who received pre-emptive fluconazole treatment (CRAG+ cohort) and 189 ART-naïve Ugandans with symptomatic cryptococcal meningitis treated with amphotericin (CM cohort). The 10-week survival was 84% (95%CI: 70-98%) in the CRAG+ cohort and 57% (95%CI: 50%-64%) in the CM cohort. The CRAG+ cohort had improved five-year survival of 76% (95%CI: 59%-93%) compared to 42% (95%CI: 35%-50%) in the CM cohort (P = 0.001). The two cohorts had similar immunosuppression pre-ART with median CD4 counts of 15 vs. 21 CD4/mcL in the CRAG+ and CM cohorts, respectively (P = 0.45). Despite substantial early mortality, subsequent 5-year survival of persons surviving 6-months was excellent (>88%), demonstrating that long term survival is possible in resource-limited settings. Pre-ART CRAG screening with preemptive fluconazole treatment and improved CM treatment(s) are needed to reduce AIDS-attributable mortality due to cryptococcosis which remains 20-25% in sub-Saharan Africa.
authors.affiliation: Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
authors.forename: Elissa K
authors.initials: EK
authors.lastname: Butler
authors.forename: David R
authors.initials: DR
authors.lastname: Boulware
authors.forename: Paul R
authors.initials: PR
authors.lastname: Bohjanen
authors.forename: David B
authors.initials: DB
authors.lastname: Meya
mesh_terms: D000328:Adult; D000946:Antigens, Fungal / Q000097:blood*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D016919:Meningitis, Cryptococcal / Q000276:immunology / Q000503:physiopathology*; D008875:Middle Aged; D016019:Survival Analysis; D014454:Uganda
chemical_list: D000946:Antigens, Fungal