Pathways to care and outcomes among hospitalised HIV-seropositive persons with cryptococcal meningitis in South Africa

Autoři: Vanessa Quan aff001;  Sandra Toro-Silva aff002;  Charlotte Sriruttan aff003;  Verushka Chetty aff003;  Violet Chihota aff005;  Sophie Candfield aff002;  Anna Vassall aff002;  Alison D. Grant aff002;  Nelesh P. Govender aff003
Působiště autorů: GERMS-SA, Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, a division of the National Health Laboratory Service, Johannesburg, South Africa aff001;  TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom aff002;  Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, a Division of the National Health Laboratory Service, Johannesburg, South Africa aff003;  School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa aff004;  The Aurum Institute, Johannesburg, South Africa aff005;  School of Public Health, University of the Witwatersrand, Johannesburg, South Africa aff006;  The Mortimer Market Centre, Central and North West NHS Foundation Trust, London, United Kingdom aff007;  Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa aff008
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article
doi: 10.1371/journal.pone.0225742



Cryptococcus causes 15% of AIDS-related deaths and in South Africa, with its high HIV burden, is the dominant cause of adult meningitis. Cryptococcal meningitis (CM) mortality is high, partly because patients enter care with advanced HIV disease and because of failure of integrated care following CM diagnosis. We evaluated pathways to hospital care, missed opportunities for HIV testing and initiation of care.


We performed a cross-sectional study at five public-sector urban hospitals. We enrolled adults admitted with a first or recurrent episode of cryptococcal meningitis. Study nurses conducted interviews, supplemented by a prospective review of medical charts and laboratory records.


From May to October 2015, 102 participants were enrolled; median age was 40 years (interquartile range [IQR] 33.9–46.7) and 56 (55%) were male. In the six weeks prior to admission, 2/102 participants were asymptomatic, 72/100 participants sought care at a public-sector facility, 16/100 paid for private health care. The median time from seeking care to admission was 4 days (IQR, 0–27 days). Of 94 HIV-seropositive participants, only 62 (66%) knew their status and 41/62 (66%) had ever taken antiretroviral treatment. Among 13 participants with a known previous CM episode, none were taking fluconazole maintenance therapy. In-hospital management was mostly amphotericin B; in-hospital mortality was high (28/92, 30%). Sixty-four participants were discharged, 92% (59/64) on maintenance fluconazole, 4% (3/64) not on fluconazole and 3% (2/64) unknown. Twelve weeks post-discharge, 31/64 (48%) participants were lost to follow up. By 12 weeks post discharge 7/33 (21%) had died. Interviewed patients were asked if they were still on fluconazole, 11% (2/18) were not.


Among hospitalised participants with CM, there were many missed opportunities for HIV care and linkage to ART prior to admission. Universal reflex CrAg screening may prompt earlier diagnosis of cryptococcal meningitis but there is a wider problem of timely linkage to care for HIV-seropositive people.

Klíčová slova:

Cryptococcal meningitis – Cryptococcosis – Cryptococcus – HIV diagnosis and management – Hospitals – Nurses – Reflexes


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2019 Číslo 12