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Implementation of new Cryptococcal Meningitis screening, prevention, and treatment guidelines in Tanzania

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BACKGROUND: Cryptococcal meningitis (CM) causes approximately 15% of HIV-related deaths globally, the majority in sub-Saharan Africa. We describe findings from a technical assistance program supporting implementation of new CM screening and treatment guidelines in Tanzania.
DESCRIPTION: Activities included dissemination of new CMguidelines, supply chain support, and mentoring at 15 health facilities in November 2019, February 2020, and March 2021. Staff surveys assessed facility procedures, supplies, and implementation challenges. Three-months of outpatient records were abstracted at each visit to assess screening of HIV clients; inpatient records were reviewed for CM diagnosis, treatment, and clinical disposition. Data were summarized using counts and proportions.
LESSONS LEARNED: Overall, 2,181 inpatient and outpatient clients with advanced HIV disease received cryptococcal antigen (CrAg) serum screening; 270 (12.3%) were positive. Of the 112 outpatient clients who tested positive for CrAg, 73 (65%) were screened for symptoms of meningitis. More than half (55%) of the 27 clients who were symptomatic were hospitalized for CSF testing. Among the 46 asymptomatic clients, 43 (93%) started pre-emptive therapy with Fluconazole. More than half (53%) of facilities reported frequent fluconazole shortages in 2019, but only 1 (7%) continued to report shortages in 2021. All 15 facilities reported shortages of Amphotericin B and 5FC in 2021. Data between inpatient and outpatient departments could not be linked due to separate records systems. A total of 268 clients were treated for CM in inpatient settings. Fifty-eight (21.6%) inpatient clients received a lumbar puncture (LP) for cerebrospinal fluid analysis and cryptococcus testing; 26 (44.8%) were positive. Patient files did not include a reason for not performing LP diagnostic confirmation in 210 (78.3%) clients. Staff surveyed listed patient condition, lack of equipment and failure of patients to pay as reasons for not conducting LP. Inpatients were treated with Fluconazole monotherapy (76.9%), Fluconazole and Amphotericin B (7.1%), and Amphotericin B alone (0.3%).
CONCLUSIONS: Implementation challenges following adoption of new CM guidelines in Tanzania include supply shortages, data linkage limitations, few LP procedures and inadequate management of Cryptococcal meningitis. Ongoing support is needed to address barriers and increase successful screening and treatment of clients with advanced HIV disease.