Cape Town - UCT researchers have found that starting HIV-positive patients on antiretrovirals while they have a meningitis infection could prove fatal.
The latest findings of the Cryptococcal Optimal Antiretroviral Timing (Coat) clinical trial, which tested treatment options of this common HIV/Aids-related infection, are so weighty that they are already used to inform international HIV-treatment guidelines.
While ARVs are generally associated with wellness and improved survival of those with HIV/Aids from opportunistic infections, the latest study showed that the exact opposite applied to those with cryptococcal meningitis.
Researchers found that early ARV treatment before the infection is cleared may instead result in increased inflammation of the brain, leading to death.
Fungal infections are the second-most common cause of death among HIV-positive people after tuberculosis.
Out of about 7 000 cryptococcal meningitis cases diagnosed by the National Institute of Communicable Diseases in the country, about 99 percent are attributed to people who are HIV-positive.
Cryptococcal meningitis, which lives in the environment and is contracted through breathing, is now the most common cause of infection in adults on the continent.
In the latest study, which was published in the New England Journal last week, researchers from UCT, the University of Minnesota, and Mbarara and Makerere universities in Uganda found that delaying ARV treatment to between five and six weeks after meningitis treatment resulted in a 15 percent better survival rate than starting ARVs between the first and second week of treatment.
The mortality rate in the first 26 weeks of treatment was much higher, at about 45 percent, among those who started on ARVs much earlier, compared with 30 percent of those on delayed ARV therapy.
Professor Graeme Meintjies, UCT’s infectious disease specialist who conducted the study at GF Jooste Hospital (one of the three study sites), said with the latest results already influencing international HIV guidelines, including those of the World Health Organisation, it was apparent that patients with meningitis should be fully treated in hospital and only be introduced to ARVs once their symptoms improved.
While with most infections better immune function was regarded as favourable to help fight infection, there seemed to be a paradox with meningitis.
“A severely damaged immune system which is rapidly rebounding with ARVs can generate too much inflammation and actually make patients more ill.”
This paradoxical reaction to therapy, known as immune reconstitution inflammatory syndrome, was rarely fatal for most types of infections.
“But brain infections appear to be different. When this inflammatory reaction occurs in the brain, death can occur,” Meintjies said.
Cape Argus