Browsing by Author "Meya, David"

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    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
    (Open forum infectious diseases, 2022) Okwir, Mark; Link, Abigail; Rhein, Joshua; Obbo, John Stephen; Okello, James; Nabongo, Betty; Alal, Jimmy; Meya, David; Bohjanen, Paul R.
    Background. The impact of the “test and treat” program for human immunodeficiency virus (HIV) treatment in rural areas of Uganda on cryptococcal antigen (CrAg) screening or cryptococcal meningitis (CM) is poorly understood. Methods. We retrospectively evaluated clinical factors in 212 HIV-infected patients diagnosed with CM from February of 2017 to November of 2019 at Lira Regional Referral Hospital in northern Uganda. Results. Among 212 patients diagnosed with CM, 58.5% were male. Median age was 35 years; CD4 count and HIV viral load (VL) were 86 cells/μL and 9463 copies/mL, respectively. Only 10% of patients had a previous history of CM. We found that 190 of 209 (90.9%) patients were ART experienced and 19 (9.1%) were ART naive. Overall, 90 of 212 (42.5%) patients died while hospital ized (median time to death, 14 days). Increased risk of death was associated with altered mental status (hazard ratio [HR], 6.6 [95% confidence interval {CI}, 2.411–18.219]; P ≤ .0001) and seizures (HR, 5.23 [95% CI, 1.245–21.991]; P = .024). Conclusions. Current guidelines recommend CrAg screening based on low CD4 counts for ART-naive patients and VL or clin ical failure for ART-experienced patients. Using current guidelines for CrAg screening, some ART-experienced patients miss CrAg screening in resource-limited settings, when CD4 or VL tests are unavailable. We found that the majority of HIV-infected patients with CM were ART experienced (90.9%) at presentation. The high burden of CM in ART-experienced patients supports a need for improved CrAg screening of ART-exposed patients. Keywords. antiretroviral therapy; cryptococcal meningitis outcomes; screening.
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    Impact of a Cryptococcal meningitis diagnosis and treatment program at Lira Regional Referral Hospital in rural, Northern Uganda
    (PLOS global public health, 2022) Link, Abigail; Okwir, Mark; Meya, David; Nabongo, Betty; Okello, James; Kasprzyk, Danuta; Bohjanen, Paul R.
    Abstract In rural areas of sub-Saharan Africa, infrastructure and resources for treatment of crypto coccal meningitis (CM) are often lacking. We introduced a CM diagnosis and treatment pro gram (CM-DTP) at Lira Regional Referral Hospital (LRRH) in rural Uganda to determine if implementing high-quality standard of care protocols would improve outcomes. Information extracted from hospital charts and clinical record forms at LRRH were used to compare diagnoses, treatments, and outcomes for all patients diagnosed with meningitis (n = 281) over a two-year period after initiation of the CM-DTP in February of 2017 to all patients diag nosed with meningitis (n = 215) in the two preceding years. After implementation of the CM DTP, we observed increased confirmed diagnoses of CM from 22.2% (48 of 215) to 35.2% (99 of 281), (p = 0.002) among all patients diagnosed with meningitis. Among all patients treated for CM, the proportion who received standard of care treatment with amphotericin B plus fluconazole increased from 63 of 127 (49.6%) to 109 of 146 (74.7%), (p <0.001) and mortality improved from 66 of 127 (52.0%) to 57 of 146 (39.0%), (p = 0.04) after implementa tion of the CM-DTP. Implementation of the CM-DTP was associated with increased number of lumbar punctures and decreased use of antibiotics in patients with CM, as well as decreased mortality among patients with meningitis from all causes. Improved diagnosis, treatment, and mortality were observed following implementation of the CM-DTP. Our results demonstrate that quality treatment of CM in rural Uganda is feasible
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    Lack of education, knowledge, and supplies are barriers to cryptococcal meningitis care among nurses and other healthcare providers in rural Uganda: A mixed methods study
    (Nurse Education Today, 2023) Link, Abigail; Okwir, Mark; Irebarren, Sarah; Meya, David; Bolijanen, Paul. R.; Danuta, Kasprzyk
    Abstract Background Cryptococcal meningitis (CM) is one of the deadliest opportunistic infections related to HIV/AIDS. A research gap exists surrounding the barriers to CM diagnosis, treatment delivery, and care from the healthcare provider's perspective. Objectives The purpose of this study was to elucidate provider's behaviors, to identify barriers and facilitators to diagnose and treat CM, and to assess their knowledge of CM, cryptococcal screening, and treatment. Design, setting, and participants A convergent mixed-methods study among twenty healthcare providers who provided CM patient referrals to Lira Regional Referral Hospital in Lira, Uganda. Methods Surveys and interviews were conducted to obtain information from healthcare providers who referred CM patients to Lira Regional Referral Hospital from 2017 to 2019. Questions related to provider education, knowledge, barriers to CM care, and patient education were inquired to understand the providers' perspectives. Results Nurses had the least amount of CM knowledge with half knowing the cause of CM. Approximately half the participants knew about CM transmission, but only 15 % knew the duration of CM maintenance therapy. Most participants (74 %) last had education regarding CM during didactic training. In addition, 25 % disclosed they never educate patients due to time constraints (30 %) and lack of knowledge (30 %). Nurses (75 %) were least likely to provide patient education. Most participants acknowledged their lack of CM knowledge and attributed it to a lack of education and perceived inexperience with CM. Conclusions Providers' gaps in knowledge due to the lack of education and experience contributes to decreased patient education, and the lack of access to appropriate supplies affects their provision for CM diagnosis, treatment, and care. These results can guide evidence-based interventions to improve health providers' knowledge. Recommendations for standardized CM education should be developed for both providers and patients in collaboration with professional boards and the Uganda Ministry of Health
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    Poor long-term outcomes despite improved hospital survival for patients with cryptococcal meningitis in rural, Northern Uganda
    (PLoS ONE, 2024) Okwir, Mark; Link, Abigail; Opio, Bosco; Okello, Fred; Nakato, Ritah; Nabongo, Betty; Alal, Jimmy; Rhein, Joshua; Meya, David; Liu, Yu; Bohjanen, Paul R.
    Background Cryptococcal meningitis (CM) remains a major cause of death among people living with HIV in rural sub-Saharan Africa. We previously reported that a CM diagnosis and treatment program (CM-DTP) improved hospital survival for CM patients in rural, northern Uganda. This study aimed to evaluate the impact on long-term survival. Methods We conducted a retrospective study at Lira Regional Referral Hospital in Uganda evaluating long-term survival (�1 year) of CM patients diagnosed after CM-DTP initiation (February 2017-September 2021). We compared with a baseline historical group of CM patients before CM-DTP implementation (January 2015-February 2017). Using Cox proportional hazards models, we assessed time-to-death in these groups, adjusting for confounders. Results We identified 318 CM patients, 105 in the Historical Group, and 213 in the CM-DTP Group. The Historical Group had a higher 30-day mortality of 78.5% compared to 42.2% in the CMDTP Group. The overall survival rate for the CM-DTP group at three years was 25.6%. Attendance at follow-up visits (HR:0.13, 95% CI: [0.03–0.53], p <0.001), ART adherence (HR:0.27, 95% CI: [0.10–0.71], p = 0.008), and fluconazole adherence: (HR:0.03, 95% CI: [0.01–0.13], p <0.001), weight >50kg (HR:0.54, 95% CI: [0.35–0.84], p = 0.006), and performance of therapeutic lumbar punctures (HR:0.42, 95% CI: [0.24–0.71], p = 0.001), were associated with lower risk of death. Altered mentation was associated with increased death risk (HR: 1.63, 95% CI: 1.10–2.42, p = 0.016). Conclusion Long-term survival of CM patients improved after the initiation of the CM-DTP. Despite this improved survival, long-term outcomes remained sub-optimal, suggesting that further work is needed to enhance long-term survival.