Mortality from HIV-associated meningitis in sub-Saharan Africa: a systematic review and meta-analysis.

INTRODUCTION: HIV-associated cryptococcal, TB and pneumococcal meningitis are the leading causes of adult meningitis in sub-Saharan Africa (SSA). We performed a systematic review and meta-analysis with the primary aim of estimating mortality from major causes of adult meningitis in routine care settings, and to contrast this with outcomes from clinical trial settings. METHODS: We searched PubMed, EMBASE and the Cochrane Library for published clinical trials (defined as randomized-controlled trials (RCTs) or investigator-managed prospective cohorts) and observational studies that evaluated outcomes of adult meningitis in SSA from 1 January 1990 through 15 September 2019. We performed random effects modelling to estimate pooled mortality, both in clinical trial and routine care settings. Outcomes were stratified as short-term (in-hospital or two weeks), medium-term (up to 10 weeks) and long-term (up to six months). RESULTS AND DISCUSSION: Seventy-nine studies met inclusion criteria. In routine care settings, pooled short-term mortality from cryptococcal meningitis was 44% (95% confidence interval (95% CI):39% to 49%, 40 studies), which did not differ between amphotericin (either alone or with fluconazole) and fluconazole-based induction regimens, and was twofold higher than pooled mortality in clinical trials using amphotericin based treatment (21% (95% CI:17% to 25%), 17 studies). Pooled short-term mortality of TB meningitis was 46% (95% CI: 33% to 59%, 11 studies, all routine care). For pneumococcal meningitis, pooled short-term mortality was 54% in routine care settings (95% CI:44% to 64%, nine studies), with similar mortality reported in two included randomized-controlled trials. Few studies evaluated long-term outcomes. CONCLUSIONS: Mortality rates from HIV-associated meningitis in SSA are very high under routine care conditions. Better strategies are needed to reduce mortality from HIV-associated meningitis in the region

Les Modalites Evolutives Du Zona Au Cours De L\'infection A Vih Au Cameroun

Introduction et But Peu d\'informations sont disponibles sur les complications du zona et la prise en charge globale de cette maladie chez les patients VIH-positifs dans les pays d\'Afrique sub Saharienne à l\'instar du Cameroun. Le taux de séroprévalence du VIH dans la population adulte générale au Cameroun à été rapporté à 5.5%. Notre étude visait à identifier les différentes modalités évolutives du zona au cours de l\'infection à VIH, en présence ou non d\'un traitement spécifique anti-herpétique et à explorer les pratiques thérapeutiques courantes. Matériel et Méthodes Il s\'agissait d\'une étude rétrospective et multicentrique sur 217 cas de zona, retenus parmi les 8000 consultations de dermatologie dans 4 hôpitaux universitaires de 1997 à 2002. La sérologie VIH était réalisée chez 90 patients. Résultats La séropositivité au VIH était de 85,55 % dans notre échantillon. La valeur prédictive positive du zona pour le VIH était de 79,22%. 42% des patients présentaient des modalités évolutives susceptibles de donner naissance à des complications à long terme de leur zona: névralgies post zostériennes 57,14% qui était plus fréquente chez les patients HIV positifs (p = 0,034); impétiginisation des lésions 17,58% ; cicatrices hypertrophiques 6,6% ; caractère multi métamérique 3,68 % et récidives 5,53%. 67,28 % des cas ont bénéficié d\'un traitement antiviral spécifique dont 106 patients traités à l\'Acyclovir et 40 à la valacyclovir. Parmi ces patients traités, 13,14% présentaient une névralgie post zostérienne contre 42,5 % parmi ceux n\'ayant pas reçu de traitement spécifique (p < 0,0001). Conclusion La névralgie post zostérienne est la complication la plus fréquente rencontrée au cours de l\'évolution du zona, et plus fréquente chez des patients VIH-positifs. A notre connaissance, cette étude est la première au Cameroun, faisant état d\'une réduction significative du risque de survenue de cette complication après prise d\'un traitement spécifique anti-herpétique. Cependant, il n\'en demeure pas moins que la disponibilité des ces molécules et leur accessibilité financière constituent un défi à relever en vue d\'un accès équitable aux soins pour les populations en Afrique sub saharienne. Introduction and Aim &#8232;Information on the management practices and outcome of Herpes zoster (shingles) during HIV infection is rather scarce in Sub Saharan African (SSA) countries like Cameroon. HIV seropositivity is reported to be 5.5% in the Cameroonian general adult population. We therefore decided to review the clinical course of Herpes zoster infection in the presence or absence of specific antiherpetic treatment, within the context of HIV infection in Cameroon. Materials and Methods This was a retrospective multi-centre study of 217 cases of shingles sampled from 8000 patients received in dermatology consultations in 4 University Teaching Hospitals in Yaounde and Douala between 1997 and 2002. HIV testing was done in 90 patients. Results HIV seropositivity was found in 85.55 % of cases. The positive predictive value of Herpes zoster for HIV infection was found to be 79.22%. Forty-two (42) % of the patients presented with a clinical course that led to long term complications: post-herpetic neuralgia in 57.14%, significantly more frequent in HIV positive patients (p = 0,034); impetiginisation of lesions in 17.58%; hypertrophic lesions in 6.6%; multi-dermatomal presentation in 3.68 % and recurrences in 5.53% of patients. Specific antiherpetic treatment was administered to 67.28 % of patients (106 patients treated with Acyclovir and 40 with Valacyclovir). This specific antiviral treatment significantly reduced the risk of developing post-herpetic neuralgia as only 13.14% of treated patients presented this complication compared to 42.5 % untreated patients (p < 0.0001). Conclusions Post-herpetic neuralgia is the most common complication of Herpes zoster and more common in HIV patients in our study population. To our knowledge, this is the first report in Cameroon of a significant reduction of the risk of post-herpetic neuralgia in HIV-positive patients with shingles who receive specific antiherpetic treatment. However, the availability and financial accessibility to these drugs are still major challenges which need to be addressed in order to contribute to the global access to health for the peoples of SSA. Keywords: HIV, Herpes zoster/shingles, treatment accessibility, evolution, Sub Saharan Africa.African Journal of Neurological Sciences Vol. 25 (2) 2006: pp. 21-2