| dc.description.abstract | Background: Despite major progress in HIV therapy and management, cryptococcal meningitis (Mbonigaba et al.) remains an important cause of morbidity and mortality among people living with HIV (PLWHIV) in Uganda, including significant neurocognitive impairment. However, there is a paucity of evidence about the magnitude of sustained neurocognitive impairment and associated factors among CM survivors. Objective: To determine the prevalence and risk factors for sustained neurocognitive impairment among HIV seropositive cryptococcal meningitis survivors enrolled in the ASTRO-CM randomized controlled trial at two tertiary hospitals in Uganda namely: Mulago and Mbarara hospitals.
Methods: In a retrospective analysis, data from 210 HIV seropositive adults with cryptococcal meningitis (Mbonigaba et al.) was reviewed using secondary data from the ASTRO-CM cohort study in Uganda. The primary study included adults over 18 years who underwent Neurocognitive Assessment (NCA) at three months. A Quantitative Neurocognitive Performance Z (QNPZ) score was calculated using 8 tests, with a cutoff of -1 standard deviation indicating impaired neurocognition. Modified Poisson regression evaluated factors associated with sustained NCI. In-depth interviews (10 participants) and key informant interviews (5 participants) explored additional factors related to sustained neurocognitive impairment in HIV-positive cryptococcal meningitis survivors enrolled in ASTRO-CM. Findings: Prevalence of NCI was 72.4% at 3 months post-diagnosis. Age above 25 (Adj. RR: 1.66), above primary education (Adj. RR:0.66), Glasgow Coma Scale <15 (Adj. RR:1.22), seizures (Adj. RR:1.14), CD4 count > 50(Adj. RR:1.12), high CSF fungal burden (Adj. RR:1.16), and CSF sterility on day 0 (Adj. RR:0.73) were significantly associated with NCI.
Qualitative findings further reveal that patient, facility, and health worker factors including delays in identification of symptoms, seeking of appropriate care, proper and timely diagnosis, administration of and adherence to prescribed treatment result in neurocognitive impairment 3 months post CM diagnosis. Among the individual factors, late presentation, LP refusal, seeking alternative care, and poor support systems especially post-discharge were the most common factors. Although the individual factors took precedence, the health facility factors such as drug and diagnostic tools stockouts as well as inadequate facilities to monitor drug toxicities were common challenges that resulted in poorer neurocognitive outcomes. Conclusion and Recommendations: There is a need for implementing partners and health workers to develop risk stratification algorithms based on the risk factors to better anticipate poor neurocognitive impairment in this population. Neurocognitive rehabilitation should be considered for CM survivors especially those aged, above 25, with a low education level, GCS<15, seizures, CD4 count > 50cells/L, high CSF fungal burden, and non-sterile CSF on day 0. The implementing partners should ensure better logistics for screening, diagnosing, and treating CM including monitoring drug-related toxicities, staffing in health facilities as well as rehabilitating the survivors. Sensitization strategies should target individuals at risk of CM especially those living with HIV with a CD4 count < 200, caregivers and health workers. The sensitization package should emphasize routine HIV and CD4 count testing, symptom identification, good health-seeking behaviours including the health facilities to seek care from for CM-related symptoms, demystifying lumbar punctures, drug adherence, and the importance of social support especially after discharge. Health workers should have regular training to ensure timely diagnosis, treatment, and referral of CM patients as well as the need for linkage to care such as physiotherapy and counselling to enhance drug adherence and management of CM sequelae post-discharge | en_US |
