Current Epidemiology and Clinical Features of Cryptococcus Infection in Patients Without Human Immunodeficiency Virus: A Multicenter Study in 46 Hospitals in Australia and New Zealand.

BACKGROUND: Patients without human immunodeficiency virus (HIV) are increasingly recognized as being at risk for cryptococcosis. Knowledge of characteristics of cryptococcosis in these patients remains incomplete. METHODS: We conducted a retrospective study of cryptococcosis in 46 Australian and New Zealand hospitals to compare its frequency in patients with and without HIV and describe its characteristics in patients without HIV. Patients with cryptococcosis between January 2015 and December 2019 were included. RESULTS: Of 475 patients with cryptococcosis, 90% were without HIV (426 of 475) with marked predominance in both Cryptococcus neoformans (88.7%) and Cryptococcus gattii cases (94.3%). Most patients without HIV (60.8%) had a known immunocompromising condition: cancer (n = 91), organ transplantation (n = 81), or other immunocompromising condition (n = 97). Cryptococcosis presented as incidental imaging findings in 16.4% of patients (70 of 426). The serum cryptococcal antigen test was positive in 85.1% of tested patients (319 of 375); high titers independently predicted risk of central nervous system involvement. Lumbar puncture was performed in 167 patients to screen for asymptomatic meningitis, with a positivity rate of 13.2% where meningitis could have been predicted by a high serum cryptococcal antigen titer and/or fungemia in 95% of evaluable cases. One-year all-cause mortality was 20.9% in patients without HIV and 21.7% in patients with HIV (P = .89). CONCLUSIONS: Ninety percent of cryptococcosis cases occurred in patients without HIV (89% and 94% for C. neoformans and C. gattii, respectively). Emerging patient risk groups were evident. A high level of awareness is warranted to diagnose cryptococcosis in patients without HIV.

Outreach nurses critical for delivery of HIV care to women in western Victoria.

Women living with HIV in regional Victoria face barriers accessing care. We evaluated the care cascade and outreach nurse support required for women attending our service between 2005 and 2020. A total of 33 women attended; 97% (32/33) were on antiretroviral therapy; 67% (22/33) retained in care, 27% (9/33) transferred and 6% (2/33) lost to follow up. Of women retained in care, 95% (21/22) were on antiretroviral therapy and 91% (20/22) had virological suppression. A total of 91% (30/33) required outreach nurse care (median care episodes 100/woman; IQR 44-179) - most frequently (87%; 26/30) liaising with pharmacies and prescribers. Outreach nurses are critical in achieving UNAIDS targets for women in western Victoria.

Cost of best-practice primary care management of chronic disease in a remote Aboriginal community.

OBJECTIVE: To estimate the cost of completing all chronic care tasks recommended by the Central Australian Rural Practitioners Association Standard Treatment Manual (CARPA STM) for patients with type 2 diabetes and chronic kidney disease (CKD). DESIGN AND SETTING: The study was conducted at a health service in a remote Central Australian Aboriginal community between July 2010 and May 2011. The chronic care tasks required were ascertained from the CARPA STM. The clinic database was reviewed for data on disease prevalence and adherence to CARPA STM guidelines. Recommended tasks were observed in a time-and-motion study of clinicians' work. Clinicians were interviewed about systematic management and its barriers. Expenditure records were analysed for salary and administrative costs. MAIN OUTCOME MEASURES: Diabetes and CKD prevalence; time spent on chronic disease care tasks; completion of tasks recommended by the CARPA STM; barriers to systematic care identified by clinicians; and estimated costs of optimal primary care management of all residents with diabetes or CKD. RESULTS: Projected annual costs of best-practice care for diabetes and CKD for this community of 542 people were $900 792, of which $645 313 would be met directly by the local primary care service. Estimated actual expenditure for these conditions in 2009-10 was $446 585, giving a projected funding gap of $198 728 per annum, or $1733 per patient. High staff turnover, acute care workload and low health literacy also hindered optimal chronic disease care. CONCLUSION: Barriers to optimal care included inadequate funding and workforce issues. Reduction of avoidable hospital admissions and overall costs necessitates adequate funding of primary care of chronic disease in remote communities.