Now showing items 1-20 of 348

    • An Epidemic of Suspicion - Ebola and Violence in the DRC

      Nguyen, VK (Massachusetts Medical Society, 2019-04-04)
      Until the 2014 Ebola epidemic in West Africa, Ebola outbreaks had been sporadic, small, and largely confined to isolated rural villages in Central Africa. But the 2014 epidemic broke all the rules and killed more than 15,000 people; since then, more outbreaks have been reaching larger urban centers, sometimes resulting in uncontrolled spread. The current epidemic in the Democratic Republic of Congo (DRC) has triggered a massive international response, which has been met by violence, culminating in attacks at the end of February that partially destroyed Ebola treatment units in the regional hub of Butembo and its township, Katwa. This area is the epicenter of the epidemic, which is likely to be fueled by any breakdown of isolation and treatment efforts.
    • 2017 Outbreak of Ebola Virus Disease in Northern Democratic Republic of Congo

      Nsio, J; Kapetshi, J; Makiala, S; Raymond, F; Tshapenda, G; Boucher, N; Corbeil, J; Okitandjate, A; Mbuyi, G; Kiyele, M; Mondonge, V; Kikoo, MJ; Van Herp, M; Barboza, P; Petrucci, R; Benedetti, G; Formenty, P; Muzinga, BM; Kalenga, OI; Ahuka, S; Fausther-Bovendo, H; Ilunga, BK; Kobinger, GP; Muyembe, JJT (Oxford University Press, 2019-04-03)
      Background In 2017, the Democratic Republic of the Congo (DRC) recorded its eighth Ebola virus disease (EVD) outbreak, approximately 3 years after the previous outbreak. Methods Suspect cases of EVD were identified on the basis of clinical and epidemiological information. Reverse transcription–polymerase chain reaction (RT-PCR) analysis or serological testing was used to confirm Ebola virus infection in suspected cases. The causative virus was later sequenced from a RT-PCR–positive individual and assessed using phylogenetic analysis. Results Three probable and 5 laboratory-confirmed cases of EVD were recorded between 27 March and 1 July 2017 in the DRC. Fifty percent of cases died from the infection. EVD cases were detected in 4 separate areas, resulting in > 270 contacts monitored. The complete genome of the causative agent, a variant from the Zaireebolavirus species, denoted Ebola virus Muyembe, was obtained using next-generation sequencing. This variant is genetically closest, with 98.73% homology, to the Ebola virus Mayinga variant isolated from the first DRC outbreaks in 1976–1977. Conclusion A single spillover event into the human population is responsible for this DRC outbreak. Human-to-human transmission resulted in limited dissemination of the causative agent, a novel Ebola virus variant closely related to the initial Mayinga variant isolated in 1976–1977 in the DRC.
    • Antibiotic Resistance in Pacific Island Countries and Territories: A Systematic Scoping Review

      Foxlee, ND; Townell, N; McIver, L; Lau, CL (Multidisciplinary Digital Publishing Institute, 2019-03-19)
      Several studies have investigated antimicrobial resistance in low- and middle-income countries, but to date little attention has been paid to the Pacific Islands Countries and Territories (PICTs). This study aims to review the literature on antibiotic resistance (ABR) in healthcare settings in PICTs to inform further research and future policy development for the region. Following the PRISMA-ScR checklist health databases and grey literature sources were searched. Three reviewers independently screened the literature for inclusion, data was extracted using a charting tool and the results were described and synthesised. Sixty-five studies about ABR in PICTs were identified and these are primarily about New Caledonia, Fiji and Papua New Guinea. Ten PICTs contributed the remaining 21 studies and nine PICTs were not represented. The predominant gram-positive pathogen reported was community-acquired methicillin resistant S. aureus and the rates of resistance ranged widely (>50% to <20%). Resistance reported in gram-negative pathogens was mainly associated with healthcare-associated infections (HCAIs). Extended spectrum beta-lactamase (ESBL) producing K. pneumoniae isolates were reported in New Caledonia (3.4%) and Fiji (22%) and carbapenem resistant A. baumannii (CR-ab) isolates in the French Territories (24.8%). ABR is a problem in the PICTs, but the epidemiology requires further characterisation. Action on strengthening surveillance in PICTs needs to be prioritised so strategies to contain ABR can be fully realised.
    • Clinical Practice Guidelines for Chagas Disease: Recent Developments and Future Needs

      Forsyth, C; Marchiol, A; Herazo, R; Chatelain, E; Batista, C; Strub-Wourgraft, N; Bilbe, G; Sosa-Estani, S (Brazilian Society of Tropical Medicine, 2019-03-08)
    • Diagnostics for filovirus detection: impact of recent outbreaks on the diagnostic landscape

      Emperador DM; Mazzola LT; Trainor BW; Chua A; Kelly-Cirino C (BMJ Publishing Group, 2019-02-07)
      Ebolaviruses and Marburg virus (MARV) both belong to the family Filoviridae and cause severe haemorrhagic fever in humans. Due to high mortality rates and potential for spread from rural to urban regions, they are listed on the WHO R&D blueprint of high-priority pathogens. Recent ebolavirus outbreaks in Western and Central Africa have highlighted the importance of diagnostic testing in epidemic preparedness for these pathogens and led to the rapid development of a number of commercially available benchtop and point-of-care nucleic acid amplification tests as well as serological assays and rapid diagnostic tests. Despite these advancements, challenges still remain. While products approved under emergency use licenses during outbreak periods may continue to be used post-outbreak, a lack of clarity and incentive surrounding the regulatory approval pathway during non-outbreak periods has deterred many manufacturers from seeking full approvals. Waning of funding and poor access to samples after the 2014–2016 outbreak also contributed to cessation of development once the outbreak was declared over. There is a need for tests with improved sensitivity and specificity, and assays that can use alternative sample types could reduce the need for invasive procedures and expensive equipment, making testing in field conditions more feasible. For MARV, availability of diagnostic tests is still limited, restricted to a single ELISA test and assay panels designed to differentiate between multiple pathogens. It may be helpful to extend the target product profile for ebolavirus diagnostics to include MARV, as the viruses have many overlapping characteristics.
    • Demonstration of the Diagnostic Agreement of Capillary and Venous Blood Samples, Using Hepatitis-C Virus SD Bioline© Rapid Test: A Clinic-based Study

      Sun, C; Iwamoto, M; Calzia, A; Sreng, B; Yann, S; Pin, S; Lastrucci, C; Kimchamroeun, S; Dimanche, C; Dousset, JP; Le Paih, M; Balkan, S; Marquardt, T; Carnimeo, V; Lissouba, P; Maman, D; Loarec, A (Elsevier, 2019-02)
      Simplifying hepatitis C virus (HCV) screening is a key step in achieving the elimination of HCV as a global public health threat by 2030.
    • Accelerating the Elimination of Viral Hepatitis: a Lancet Gastroenterology & Hepatology Commission.

      Cooke, GS; Andrieux-Meyer, I; Applegate, TL; Atun, R; Burry, JR; Cheinquer, H; Dusheiko, G; Feld, JJ; Gore, C; Griswold, MG; Hamid, S; Hellard, ME; Hou, J; Howell, J; Jia, J; Kravchenko, N; Lazarus, JV; Lemoine, M; Lesi, OA; Maistat, L; McMahon, BJ; Razavi, H; Roberts, TR; Simmons, B; Sonderup, MW; Spearman, WC; Taylor, BE; Thomas, DL; Waked, I; Ward, JW; Wiktor, SZ (Elsevier, 2019-02-01)
      Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a greater focus on national progress towards elimination with support given, if necessary, through innovative financing measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle stigma and discrimination. We identify key examples of the progress that has already been made in many countries throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO elimination goals.
    • Post-traumatic osteomyelitis in Middle East war-wounded civilians: resistance to first-line antibiotics in selected bacteria over the decade 2006-2016.

      Fily, F; Ronat, JB; Malou, N; Kanapathipillai, R; Seguin, C; Hussein, N; Fakhri, RM; Langendorf, C (BioMed Central, 2019-01-31)
      War-wounded civilians in Middle East countries are at risk of post-traumatic osteomyelitis (PTO). We aimed to describe and compare the bacterial etiology and proportion of first-line antibiotics resistant bacteria (FLAR) among PTO cases in civilians from Syria, Iraq and Yemen admitted to the reconstructive surgical program of Médecins Sans Frontières (MSF) in Amman, Jordan, and to identify risk factors for developing PTO with FLAR bacteria.
    • Genomic Insights into the 2016-2017 Cholera Epidemic in Yemen

      Weill, FX; Domman, D; Njamkepo, E; Almesbahi, AA; Naji, M; Nasher, SS; Rakesh, A; Assiri, AM; Sharma, NC; Kariuki, S; Pourshafie, MR; Rauzier, J; Abubakar, A; Carter, JY; Wamala, JF; Seguin, C; Bouchier, C; Malliavin, T; Bakhshi, B; Abulmaali, HHN; Kumar, D; Njoroge, SM; Malik, MR; Kiiru, J; Luquero, FJ; Azman, AS; Ramamurthy, T; Thomson, NR; Quilici, ML (Nature Publishing Group, 2019-01-02)
      Yemen is currently experiencing, to our knowledge, the largest cholera epidemic in recent history. The first cases were declared in September 2016, and over 1.1 million cases and 2,300 deaths have since been reported1. Here we investigate the phylogenetic relationships, pathogenesis and determinants of antimicrobial resistance by sequencing the genomes of Vibrio cholerae isolates from the epidemic in Yemen and recent isolates from neighbouring regions. These 116 genomic sequences were placed within the phylogenetic context of a global collection of 1,087 isolates of the seventh pandemic V. cholerae serogroups O1 and O139 biotype El Tor2-4. We show that the isolates from Yemen that were collected during the two epidemiological waves of the epidemic1-the first between 28 September 2016 and 23 April 2017 (25,839 suspected cases) and the second beginning on 24 April 2017 (more than 1 million suspected cases)-are V. cholerae serotype Ogawa isolates from a single sublineage of the seventh pandemic V. cholerae O1 El Tor (7PET) lineage. Using genomic approaches, we link the epidemic in Yemen to global radiations of pandemic V. cholerae and show that this sublineage originated from South Asia and that it caused outbreaks in East Africa before appearing in Yemen. Furthermore, we show that the isolates from Yemen are susceptible to several antibiotics that are commonly used to treat cholera and to polymyxin B, resistance to which is used as a marker of the El Tor biotype.
    • Strategies for access to affordable hepatitis C testing and treatment in Asia

      Khwairakpam, G; Burry, J (2019-01)
      With increasing availability of generic direct-acting antivirals (DAAs) and associated price reductions, various governments, multilateral institutions, and donors have started providing testing and treatment for hepatitis C virus (HCV) infection. More data on the quality of these generic medicines and on cost-effectiveness of their use are becoming widely available. This review seeks to describe some of the treatment programs for HCV that are evolving in Cambodia, India, Indonesia, Malaysia, Myanmar, and Thailand.
    • From Risk to Care: The Hepatitis C Screening and Diagnostic Cascade in a Primary Health Care Clinic in Karachi, Pakistan—a Cohort Study

      Khalid, GG; Kyaw, KWY; Bousquet, C; Auat, R; Donchuk, D; Trickey, A; Hamid, S; Qureshi, H; Mazzeo, V; Aslam, K; Khowaja, S; Van den Bergh, R; Operational Center Brussels, Médecins Sans Frontières, Islamabad, Pakistan; Department of Operational Research, International Union Against Tuberculosis and Lung Disease, Mandalay, Myanmar; Operational Center Brussels, Médecins Sans Frontières, Islamabad, Pakistan; Operational Center Brussels, Brussels, Belgium; Operational Center Brussels, Brussels, Belgium; School of Social and Population Sciences, University of Bristol, Bristol, UK; Department of Medicine, Agha Khan Medical University, Karachi, Pakistan; Pakistan Health Research Council, Islamabad, Pakistan; Operational Center Brussels, Médecins Sans Frontières, Islamabad, Pakistan; Operational Center Brussels, Médecins Sans Frontières, Islamabad, Pakistan; Operational Center Brussels, Médecins Sans Frontières, Islamabad, Pakistan; Operational Center Brussels, Brussels, Belgium (Oxford University Press, 2018-12-28)
      Background In the high-prevalence setting of Pakistan, screening, diagnosis and treatment services for chronic hepatitis C (CHC) patients are commonly offered in specialized facilities. We aimed to describe the cascade of care in a Médecins Sans Frontières primary health care clinic offering CHC care in an informal settlement in Karachi, Pakistan. Methods This was a retrospective cohort analysis using routinely collected data. Three different screening algorithms were assessed among patients with one or more CHC risk factors. Results Among the 87 348 patients attending the outpatient clinic, 5003 (6%) presented with one or more risk factors. Rapid diagnostic test (RDT) positivity was 38% overall. Approximately 60% of the CHC patients across all risk categories were in the early stage of the disease, with an aspartate aminotransferase:platelet ratio index score <1. The sequential delays in the cascade differed between the three groups, with the interval between screening and treatment initiation being the shortest in the cohort tested with GeneXpert onsite. Conclusions Delays between screening and treatment can be reduced by putting in place more patient-centric testing algorithms. New strategies, to better identify and treat the hidden at-risk populations, should be developed and implemented.
    • Increased Hepatitis C Virus Co-infection and Injection Drug Use in HIV-infected Fishermen in Myanmar

      Ousley, J; Nesbitt, R; Kyaw, NTT; Bermudez, E; Soe, KP; Anicete, R; Mon, PE; Le Shwe Sin Ei, W; Christofani, S; Fernandez, M; Ciglenecki, I (BioMed Central, 2018-12-14)
      In Southeast Asia, though fishermen are known to be a key population at high risk of HIV, little is known about their co-infection rates with Hepatitis C virus (HCV), or how illness and risk behaviors vary by occupation or type of fishermen. In Myanmar, this lack of knowledge is particularly acute, despite the fact that much of the country's border is coastline.
    • Field evaluation of GeneXpert® (Cepheid) HCV performance for RNA quantification in a genotype 1 and 6 predominant patient population in Cambodia.

      Iwamoto, M; Calzia, A; Dublineau, A; Rouet, F; Nouhin, J; Yann, S; Pin, S; Sun, C; Sann, K; Dimanche, C; Lastrucci, C; Coulborn, R; Maman, D; Dousset, JP; Loarec, A (Wiley-Blackwell, 2018-12-03)
      GeneXpert® (Cepheid) is the only WHO prequalified platform for hepatitis C virus (HCV) nucleic acid amplification testing that is suitable for point-of-care use in resource-limited contexts. However, its application is constrained by the lack of evidence on genotype 6 (GT6) HCV. We evaluated its field performance among a patient population in Cambodia predominantly infected with GT6. Between August and September 2017, we tested plasma samples obtained from consenting patients at Médecins Sans Frontières' HCV clinic at Preah Kossamak Hospital for HCV viral load (VL) using GeneXpert® and compared its results to those obtained using COBAS® AmpliPrep/Cobas® TaqMan® HCV Quantitative Test, v2.0 (Roche) at the Institut Pasteur du Cambodge. Among 769 patients, 77% of the seropositive patients (n = 454/590) had detectable and quantifiable VL using Roche and 43% (n = 195/454) were GT6. The sensitivity and specificity of GeneXpert® against Roche were 100% (95% CI 99.2, 100.0) and 98.5% (95% CI 94.8, 99.8). The mean VL difference was -0.01 (95% CI -0.05, 0.02) log10  IU/mL for 454 samples quantifiable on Roche and -0.07 (95% CI -0.12, -0.02) log10  IU/mL for GT6 (n = 195). The limit of agreement (LOA) was -0.76 to 0.73 log10  IU/mL for all GTs and -0.76 to 0.62 log10 IU/mL for GT6. Twenty-nine GeneXpert® results were outside the LOA. Frequency of error and the median turnaround time (TAT) for GeneXpert® were 1% and 0 days (4 days using Roche). We demonstrated that the GeneXpert® HCV assay has good sensitivity, specificity, quantitative agreement, and TAT in a real-world, resource-limited clinical setting among GT6 HCV patients.
    • Real-Time PCR for the Evaluation of Treatment Response in Clinical Trials of Adult Chronic Chagas Disease: Usefulness of Serial Blood Sampling and qPCR Replicates

      Parrado, R; Ramirez, JC; de la Barra, A; Alonso-Vega, C; Juiz, N; Ortiz, L; Illanes, D; Torrico, F; Gascon, J; Alves, F; Flevaud, L; Garcia, L; Schijman, AG; Ribeiro, I (American Society for Microbiology, 2018-12-03)
      This work evaluated a serial blood sampling procedure to enhance the sensitivity of duplex real-time PCR (qPCR) for baseline detection and quantification of parasitic loads and post-treatment identification of failure in the context of clinical trials for treatment of chronic Chagas disease, namely DNDi-CH-E1224-001 (NCT01489228) and MSF-DNDi PCR sampling optimization study (NCT01678599). Patients from Cochabamba (N= 294), Tarija (N= 257), and Aiquile (N= 220) were enrolled. Three serial blood samples were collected at each time-point and qPCR triplicates were tested per sample. The first two samples were collected during the same day and the third one seven days later.A patient was considered PCR positive if at least one qPCR replicate was detectable. Cumulative results of multiple samples and qPCR replicates enhanced the proportion of pre-treatment sample positivity from 54.8 to 76.2%, 59.5 to 77.8%, and 73.5 to 90.2% in Cochabamba, Tarija, and Aiquile cohorts, respectively. This strategy increased the detection of treatment failure from 72.9 to 91.7%, 77.8 to 88.9%, and 42.9 to 69.1% for E1224 low, short, and high dosage regimens, respectively; and from 4.6 to 15.9% and 9.5 to 32.1% for the benznidazole arm in the DNDi-CH-E1224-001 and MSF-DNDi studies, respectively. The addition of the third blood sample and third qPCR replicate in patients with non-detectable PCR results in the first two samples, gave a small, non-statistically significant improvement in qPCR positivity. No change in clinical sensitivity was seen with a blood volume increase from 5 to 10 ml. The monitoring of patients treated with placebo in the DNDi-CH-E1224-001 trial revealed fluctuations in parasitic loads and occasional non-detectable results. In conclusion, serial sampling strategy enhanced PCR sensitivity to detecting treatment failure during follow-up and has the potential for improving recruitment capacity in Chagas disease trials, which require an initial positive qPCR result for patient admission.
    • Defining priority medical devices for cancer management: a WHO initiative

      Velazquez Berumen, A; Jimenez Moyao, G; Rodriguez, NM; Ilbawi, AM; Migliore, A; Shulman, LN (The Lancet, 2018-12)
    • Assessing the performance of real-time epidemic forecasts: A case study of Ebola in the Western Area Region of Sierra Leone, 2014-15

      Funk, S; Camacho, A; Kucharski, AJ; Lowe, R; Eggo, RM; Edmunds, WJ (London School Hygiene and Tropical Medicine, 2018-11-23)
    • Knowledge, attitude and practices of snakebite management amongest health workers in Cameroon: Need for continuous training and capacity building

      Taieb, F; Dub, T; Madec, Y; Tondeur, L; Chippaux, JP; Lebreton, M; Medang, R; Foute, FNN; Tchoffo, D; Potet, J; Alcoba, G; Comte, E; Einterz, EM; Nkwescheu, AS (Public Library of Science, 2018-10-25)
      Snakebite has only recently been recognized as a neglected tropical disease by the WHO. Knowledge regarding snakebites and its care is poor both at the population level, and at the health care staff level. The goal of this study was to describe the level of knowledge and clinical practice regarding snakebite among health care staff from Cameroon.
    • Seasonal upsurge of pneumococcal meningitis in the Central African Republic

      Crellen, T; Rao, VB; Piening, T; Zeydner, J; Siddiqui, MR (F1000Research, 2018-10-19)
      A high incidence of bacterial meningitis was observed in the Central African Republic (CAR) from December 2015 to May 2017 in three hospitals in the northwest of the country that are within the African meningitis belt. The majority of cases were caused by Streptococcus pneumoniae (249/328; 75.9%), which occurred disproportionately during the dry season (November-April) with a high case-fatality ratio of 41.6% (95% confidence interval [CI] 33.0, 50.8%). High rates of bacterial meningitis during the dry season in the meningitis belt are typically caused by Neisseria meningitidis (meningococcal meningitis), and our observations suggest that the risk of contracting S. pneumoniae (pneumococcal) meningitis is increased by the same environmental factors. Cases of meningococcal meningitis (67/328; 20.4%) observed over the same period were predominantly type W and had a lower case fatality rate of 9.6% (95% CI 3.6, 21.8%). Due to conflict and difficulties in accessing medical facilities, it is likely that the reported cases represented only a small proportion of the overall burden and that there is high underlying prevalence of S. pneumoniae carriage in the community. Nationwide vaccination campaigns in the CAR against meningitis have been limited to the use of MenAfriVac, which targets only meningococcal meningitis type A. We therefore highlight the need for expanded vaccine coverage to prevent additional causes of seasonal outbreaks.
    • Prevalence and risk factors of brucellosis among febrile patients attending a community hospital in south western Uganda

      Migisha, R; Dan N; Boum, Y; Page, AL; Zúñiga-Ripa, A; Conde-Álvarez, R; Bagenda, F; Bonnet, M (Nature Research, 2018-10-18)
      Human brucellosis, a chronic disease contracted through contact with animals and consuption of unpasteurized dairy products is underreported in limited-resource countries. This cross-sectional study aimed to determine the prevalence and risk factors of brucellosis among febrile patients attending a community hospital in South western Uganda. A questionnaire that captured socio-demographic, occupational and clinical data was administered. Blood samples were tested for Brucella antibodies using Rose Bengal Plate Test (RBPT) and blood culture with standard aerobic BACTEC bottle was done. Of 235 patients enrolled, prevalence of brucellosis (RBPT or culture confirmed) was 14.9% (95% CI 10.6-20.1) with a culture confrmation in 4.3% of the participants. The factors independently associated with brucellosis were consumption of raw milk (aOR 406.15, 95% CI 47.67-3461.69); history of brucellosis in the family (aOR 9.19, 95% CI 1.98-42.54); and selling hides and skins (aOR 162.56, 95% CI 2.86-9256.31). Hepatomegaly (p < 0.001), splenomegaly (p = 0.018) and low body mass index (p = 0.032) were more common in patients with brucellosis compared to others. Our findings reveal a high prevalence of brucellosis among febrile patients and highlight a need for implementing appropiate tests, public awareness activities and vaccination of animals to control and eliminate the disease.
    • Leave no one behind: response to new evidence and guidelines for the management of cryptococcal meningitis in low-income and middle-income countries

      Loyse, A; Burry, J; Cohn, J; Ford, N; Chiller, T; Ribeiro, I; Koulla-Shiro, S; Mghamba, J; Ramadhani, A; Nyirenda, R; Aliyu, SH; Wilson, D; Le, T; Oladele, R; Lesikari, S; Muzoora, C; Kalata, N; Temfack, E; Mapoure, Y; Sini, V; Chanda, D; Shimwela, M; Lakhi, S; Ngoma, J; Gondwe-Chunda, L; Perfect, C; Shroufi, A; Andrieux-Meyer, I; Chan, A; Schutz, C; Hosseinipour, M; Van der Horst, C; Klausner, JD; Boulware, DR; Heyderman, R; Lalloo, D; Day, J; Jarvis, JN; Rodrigues, M; Jaffar, S; Denning, D; Migone, C; Doherty, M; Lortholary, O; Dromer, F; Stack, M; Molloy, SF; Bicanic, T; van Oosterhout, J; Mwaba, P; Kanyama, C; Kouanfack, C; Mfinanga, S; Govender, N; Harrison, TS (The Lancet, 2018-10-18)
      In 2018, WHO issued guidelines for the diagnosis, prevention, and management of HIV-related cryptococcal disease. Two strategies are recommended to reduce the high mortality associated with HIV-related cryptococcal meningitis in low-income and middle-income countries (LMICs): optimised combination therapies for confirmed meningitis cases and cryptococcal antigen screening programmes for ambulatory people living with HIV who access care. WHO's preferred therapy for the treatment of HIV-related cryptococcal meningitis in LMICs is 1 week of amphotericin B plus flucytosine, and the alternative therapy is 2 weeks of fluconazole plus flucytosine. In the ACTA trial, 1-week (short course) amphotericin B plus flucytosine resulted in a 10-week mortality of 24% (95% CI -16 to 32) and 2 weeks of fluconazole and flucytosine resulted in a 10-week mortality of 35% (95% CI -29 to 41). However, with widely used fluconazole monotherapy, mortality because of HIV-related cryptococcal meningitis is approximately 70% in many African LMIC settings. Therefore, the potential to transform the management of HIV-related cryptococcal meningitis in resource-limited settings is substantial. Sustainable access to essential medicines, including flucytosine and amphotericin B, in LMICs is paramount and the focus of this Personal View.