HIV treatment can cut the risk of death in severely immune suppressed patients who have cryptococcal meningitis and HIV, researchers from Botswana report in the October 1st edition of the Journal of Acquired Immune Deficiency Syndromes.
Use of antiretroviral therapy in patients who are ill with cryptococcal meningitis can increase the risk of illness and even death by causing an immune reconstruction inflammatory syndrome to develop. HIV treatment is often deferred until the early course of therapy for the infection has been completed. However, the use of HIV treatment can also improve the chance of survival, even if symptoms of meningitis temporarily worsen. This is because anti-HIV drugs can restore the ability of the immune system to respond to infections and lead to more rapid clearance of the bacteria.
Investigators from the Princess Marina Hospital in Gaborone, Botswana therefore conducted a prospective, observational study involving patients who were admitted to hospital with cryptococcal meningitis and HIV. The study ran between 2005 and 2006 and involved 92 patients.
A total of 26 (28%) patients were receiving HIV therapy at the time cryptococcal meningitis was diagnosed. Antiretroviral therapy in all these individuals consisted of a non-nucleoside reverse transcriptase inhibitor (NNRTI) and two nucleoside reverse transcriptase inhibitors (NRTIs).
Treatment for cryptococcal meningitis with amphotericin B was started after 14 days in all patients. CD4 cell counts were conducted in 72 patients, the median count being 41 cells/mm3 in the patients not taking HIV treatment and 52 cells/mm3 in those taking anti-HIV drugs, a non-significant difference.
A total of 16 patients (17%) died during their admission to hospital for cryptococcal meningitis. The proportion of patients dying who received HIV treatment (2 of 26, 8%) was lower than the proportion of patients not taking anti-HIV drugs who died (14 of 66, 21%), but not significantly so.
But when the investigators controlled for potential confounding factors (male sex and infection with tuberculosis), they found that treatment with antiretroviral therapy was associated with a significantly reduced risk of death from cryptococcal meningitis (adjusted odds ratio 0.019, 95% CI 0.04-1.00).
“This study suggests that patients on highly active antiretroviral therapy at the time of their first diagnosis of cryptococcal meningitis have a lower in-hospital mortality during initial therapy when compared with patients who are not on [HIV treatment] at this time”, write the investigators.
The investigators say that the prospective nature of their study was a strength, but that it was limited by its small numbers and observational design.
They conclude, “although limited, these data suggest that there is a protective effect of [HIV therapy] that is manifested very early in the course of cryptococcal meningitis. As such, clinical trials evaluating the role of very early [HIV treatment] initiation on outcome should be pursued.”