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Background: Cryptococcal meningitis is a leading cause of death among HIV-infected individuals in sub-Saharan Africa. Recent developments include the availability of intravenous fluconazole, cryptococcal antigen assays and new data to support fluconazole pre-emptive treatment. In this study, we describe the impact of screening HIV-positive adult inpatients with serum cryptococcal antigen (CRAG) at a Tanzanian referral hospital., Methods: All adults admitted to the medical ward of Bugando Medical Centre are counseled and tested for HIV. In this prospective cohort study, we consecutively enrolled HIV-positive patients admitted between September 2009 and January 2010. All patients were interviewed, examined and screened with serum CRAG. Patients with positive serum CRAG or signs of meningitis underwent lumbar puncture. Patients were managed according to standard World Health Organization treatment guidelines. Discharge diagnoses and in-hospital mortality were recorded., Results: Of 333 HIV-infected adults enrolled in our study, 15 (4.4%) had confirmed cryptococcal meningitis and 10 of these 15 (66%) died. All patients with cryptococcal meningitis had at least two of four classic symptoms and signs of meningitis: fever, headache, neck stiffness and altered mental status. Cryptococcal meningitis accounted for a quarter of all in-hospital deaths., Conclusions: Despite screening of all HIV-positive adult inpatients with the serum CRAG at the time of admission and prompt treatment with high-dose intravenous fluconazole in those with confirmed cryptococcal meningitis, the in-hospital mortality rate remained unacceptably high. Improved strategies for earlier diagnosis and treatment of HIV, implementation of fluconazole pre-emptive treatment for high-risk patients and acquisition of better resources for treatment of cryptococcal meningitis are needed.

Objective: HIV-related renal dysfunction is associated with high mortality. Data on the prevalence of renal dysfunction among HIV-infected outpatients starting antiretroviral therapy (ART) in sub-Saharan Africa are limited. Recent recommendations to include the nephrotoxic drug tenofovir in first-line ART regimens make clarification of this issue urgent., Methods: We screened for renal dysfunction by measuring serum creatinine, proteinuria, and microalbuminuria in HIV-positive outpatients initiating ART in Mwanza, Tanzania. We excluded patients with pre-existing renal disease, hypertension, diabetes, or hepatitis C virus co-infection. Estimated glomerular filtration rates (eGFRs) were calculated by Cockroft-Gault and Modification of Diet in Renal Disease equations., Results: Only 129 (36%) of 355 enrolled patients had normal eGFRs (grade 0 or 1) above 90 ml/min per 1.73 m. Grade 2 renal dysfunction (eGFR between 60 and 89 ml/min per 1.73 m) was present in 137 patients (38.6%), and 87 patients (25%) had grade 3 dysfunction (eGFR between 30 and 59 ml/min per 1.73 m). Microalbuminuria and proteinuria were detected in 72 and 36% of patients, respectively. Factors predictive of renal dysfunction in multivariate analysis included female sex [odds ratio (OR) 3.0, 95% confidence interval (1.8-5.1), P < 0.0001], BMI less than 18.5 [OR 2.3 (1.3-4.1), P = 0.004], CD4 T-cell count below 200 cells/μl [OR 2.3 (1.1-4.8), P = 0.04], and WHO clinical stage II or above [OR 1.6 (1.2-2.3), P = 0.001]., Conclusion: Renal dysfunction was highly prevalent in this population of HIV-positive outpatients initiating first ART in Tanzania. This highlights the critical and underappreciated need to monitor renal function in HIV-positive patients in sub-Saharan Africa, particularly given the increasing use of tenofovir in first-line ART.