Background
WHO guidelines for HIV-associated cryptococcal meningitis were updated in June 2022 recommending single, high-dose liposomal amphotericin with 14 days of flucytosine and fluconazole. The AMBITION team who defined that regimen lead the Single High-dose AmBisome to Reduce Mortality from CM (SHARE-CM) project aiming to maximise the impact of the regimen in routine care. The project engages key stakeholders, trains healthcare workers, increases patient health-related literacy, and undertakes M&E of impact. We report progress after the first 3 years of this 5-year project.
Methods
We identified personnel at Ministries of Health and a purposively selected sample of healthcare facilities in Botswana, Malawi, Uganda and Zimbabwe. We administered national level surveys to understand current treatment guidelines, drug registration status, and drug availability. We administered facility level surveys to determine the availability of key commodities and ascertain which treatment regimens are most administered to patients. Surveys were completed online and data described.
Results
Four national surveys and 60 facility surveys (Botswana: 13, Malawi: 13, Zimbabwe 14, Uganda: 20) were completed between June 2023 – July 2024. The AMBITION regimen was first-line in each country guideline; timing of guideline dissemination varied. Key antifungals were available in each country, initially via Unitaid/CHAI funding and recently via the Global Fund. CD4 testing was available all or most of the time in 88% (53/60) of facilities; cryptococcal antigen 100% (60/60); lumbar puncture needles 63% (38/60) and manometers 25% (15/60). Liposomal amphotericin was available all or most of the time in 68% (41/60) of facilities; flucytosine 55% (33/60) and fluconazole 82% (49/60). The AMBITION regimen was the most administered regimen overall in 47% (28/60) of facilities with significant intercountry variability ranging from 15% (2/13) in Botswana to 75% in Uganda (15/20).
Conclusions
In the two years since WHO guidelines were updated, there has been rapid adoption of the AMBITION regimen in high-incidence settings. Antifungals are available in country but not always at facility level, highlighting the need to improve in-country supply chains. The AMBITION regimen was the most administered overall, with intercountry variability likely explained by different timing of guideline dissemination. Ongoing monitoring and evaluation can support improved uptake of the AMBITION regimen.