High Burden of Cryptococcal Meningitis Among Antiretroviral Therapy–Experienced Human Immunodeficiency Virus–Infected Patients in Northern Uganda in the Era of “Test and Treat”: Implications for Cryptococcal Screening Programs

Mortality from meningitis in sub-Saharan Africa (SSA) remains high at 19%–68%, and the yeast Cryptococcus neoformans is the most common cause of death among people living with human immunodeficiency virus (HIV) [1, 2]. Annual global deaths from cryptococcal meningitis (CM) are estimated at 181 100, with 135 900 deaths in SSA, and CM is responsible for 15% of all AIDS-related deaths [2]. CM comprises 60% of all meningitis cases in Uganda and is associated with high morbidity and mortality [3]. Despite the increased use of antiretroviral therapy (ART) in Africa, the burden of opportunistic infections (OIs) such as CM remains unacceptably high [4, 5]. In Uganda, the median survival for CM was 26 days in the preART era [6]. In the pre-ART era, the 10-week survival was 84% in cryptococcal antigen (CrAg)–positive patients and 57% in patients with CM. Fourteen-day survival was only 47% in the earlier studies, but survival has improved with appropriate antifungal therapy and ART; however, 5-year survival is only approximately 42% [7, 8]. The introduction of widespread ART use in SSA has created new challenges for detecting and treating OIs in HIV-infected patients after ART initiation. Many countries implemented a “test and treat” (TAT) program in which all persons found to be HIV-infected are immediately initiated on ART [9]. Although this approach has led to improved overall outcomes for HIV-infected persons, the problem of OIs such as CM remain