Long-term outcome of AIDS-associated cryptococcosis in the era of combination antiretroviral therapy

Background: Immune restoration following combination antiretroviral therapy (cART) questions the maintenance of prophylaxis among HIV-infected patients with cryptococcosis. Objective: To describe the long-term outcome after the diagnosis of cryptococcosis at the cART era. Design: Multicentre cohort of patients with a diagnosis of cryptococcosis between 1996 and 2000, follow-up until December 2002. Comparison with a historical cohort (1990-1994) for survival. Setting: Eighty-four French AIDS clinical centres. Patients: Two-hundred and forty HIV-infected adult patients at the cART era and 149 at the pre-cART era experiencing a first episode of culture-confirmed cryptococcosis. Results: In the cART era, 82/189 patients surviving more than 3 months after initiation of antifungal therapy had their maintenance therapy interrupted with a subsequent median follow-up of 19 months. Their relapse rate per 100 person-years was 0.9 [95% confidence interval (CI),0.0-2.0]. When considering the whole cART cohort, probability of reaching negative serum cryptococcal antigen was 71% after 48 months of follow-up. A CD4 cell count < 100/mu l [relative risk (RR), 5.5; 95% Cl, 1.3-22.2], antifungal therapy < 3 months over the past 6 months [RR, 5.0; 95% CI, 1.1-22.3] and serum cryptococcal antigen titre > 1/512 [RR, 3.5; 95% Cl, 1.1-10.8] were associated with a higher rate of cryptococcosis relapse. The mortality rate per 100 person-years was 15.3 [95% CI,12.2-18.4] in the cART era versus 63.8 [95% CI,53.0-74.91 in the pre-cART era although early mortality did not differ between the two periods. Conclusion: Overall survival after cryptococcosis has dramatically improved at the cART era. immune restoration and low serum cryptococcal antigen titres are associated with lower cryptococcosis relapse rates.