London School of Hygiene & Tropical Medicine

The research, published in The Lancet, suggests that a simple low-cost intervention could be an effective approach to reducing HIV-related deaths in Africa.

Researchers from the London School of Hygiene & Tropical Medicine, the National Institute of Medical Research Tanzania, the University Teaching Hospital in Zambia and St Georges University of London conducted a randomised trial of 1,999 HIV patients in Tanzania and Zambia.

They enrolled patients beginning HIV treatment who had advanced HIV disease. Most of the deaths in African HIV programmes occur in this group at around the time or just shortly after HIV treatment is started. All patients were firstly screened for tuberculosis and started quickly on HIV treatment. Patients were then given either standard care from a clinic, or given additional care which consisted of screening for cryptococcal meningitis as well as weekly home visits for the first four weeks from lay workers to support them with antiretroviral therapy.

The trial, which was conducted between February 2012 and September 2014, found deaths among patients receiving the additional screening for cryptococcal meningitis and home visits were 28% lower than those receiving standard clinic care (134 deaths and 180 deaths respectively over a 12 month follow-up period).

Cryptococcal meningitis, which is caused by a fungus, mostly occurs in people who have HIV/AIDS. According to CDC there are nearly one million new cases of cryptococcal meningitis each year worldwide, resulting in 625,000 deaths, most of which occur in sub-Saharan Africa.

Study senior author Shabbar Jaffar, Professor of Epidemiology at the London School of Hygiene & Tropical Medicine, said: "This large trial was the first of its kind and the results are very exciting. The combination of screening and community lay worker support reduced the death rate among patients with advanced HIV by almost a third. About 10 million people in Africa are on antiretroviral therapy, but there is a disparity in the number of people who die in the first year of treatment compared to wealthier regions like Europe. This new approach could begin closing that gap.

"The biggest challenge facing health care delivery in Africa is the severe shortage of clinically-qualified health care workers, particularly doctors". But our intervention involved trained lay-workers and did not add substantial burden onto doctors and nurses.

"The screening for cryptococcal meningitis was also a significant component in the success of our trial. We now know that screening combined with giving pre-emptive treatment for this type of fungal meningitis is an effective strategy in reducing the high number of HIV deaths associated with it in Africa.

"If this intervention were to be scaled-up by governments, the cost of the lay-workers plus the screening would be even lower than the $30-70 in our trial, meaning it should be even more highly cost-effective than what our study suggests."

The research was funded by the European and Developing Countries Clinical Trials Partnership (EDCTP).

Publication

• Sayoki Mfinanga, Shabbar Jaffar et al. Cryptococcal meningitis screening and community-based early adherence support in people with advanced HIV infection starting antiretroviral therapy in Tanzania and Zambia: an open-label, randomised controlled trial. The Lancet. DOI: 10.1016/S0140-6736(15)60164-7