When I recently visited a hospital ward in Kinshasa, Democratic Republic of Congo, I left feeling deeply distraught. Over a dozen patients with HIV were admitted with cryptococcal meningitis - a fungal disease which is the second-leading cause of HIV- related death. Many were diagnosed late, which meant this disease, which causes excruciating headaches, fever and neck stiffness, had advanced so much it was increasingly difficult to treat them. To make things worse, the lifesaving treatment for cryptococcal meningitis was in limited supply, with stockouts common in this hospital.
In my more than decade-long experience as an HIV clinician and researcher, I've witnessed these scenarios repeatedly across many countries in Africa. Our hospitals not only often lack the resources and capacity to diagnose HIV opportunistic infections, but they are also forced to rely on toxic and inferior drugs when newer, more effective treatments are available. This is why over 70% of people with cryptococcal meningitis in low- and middle-income countries die while in high-income countries, where appropriate treatments are more widely used, mortality is around 20-30%
This is not just a healthcare issue - it's a human rights crisis.
In 2023, AIDS-related illnesses claimed 390,000 lives in Africa, with cryptococcal meningitis responsible for nearly 130,000 of these deaths. These deaths persist because of the inequities that deny people in low- and middle-income countries (LMICs) access to treatment, violating their fundamental right to life.
For cryptococcal meningitis, the World Health Organization recommends a treatment regimen that includes liposomal amphotericin B (LAmB), flucytosine, and fluconazole. However, in Africa, two of these essential drugs - LAmB and flucytosine - are often unavailable, leaving many patients with a fluconazole monotherapy which is associated with a mortality of over 50%. According to the advanced HIV disease dashboard, only five of the 35 African countries it tracks have adopted LAmB as part of their treatment protocols and Mozambique is the only country to include it in its essential medicines list for cryptococcal meningitis.
In addition, low- and middle-income countries often pay more than high-income countries, despite bearing a far greater burden of HIV. For instance, Brazil pays $215 per vial of LAmB, while Japan and the UK pay $51 and $99, respectively. In 2021, only 28% of the
4.18 million vials sold globally went to LMICs. Such high costs discourage governments from prioritizing LAmB, forcing hospitals to continue using the amphotericin B deoxycholate formulation that has adverse side effects.
This isn't just a healthcare crisis - it's a crisis of equity.
When communities in poverty are denied access to essential medicines, it reflects a denial of their fundamental rights. As we mark World AIDS Day, this year's theme,
"Take the Rights Path," reminds us that access to healthcare is a fundamental human right enshrined in the Universal Declaration of Human Rights. Taking the Rights path means ensuring that medicines are:
Available – Treatments for cryptococcal meningitis are frequently unavailable at country-level in many African countries due to stockouts, supply and budgeting issues. In the case of LAmB, only two generic manufacturers exist today, and both are focusing on lucrative markets in high-income countries. While the Drugs for Neglected Diseases initiative (DNDi), in collaboration with Unitaid and the Clinton Health Access Initiative are working to expand availability by engaging new generic manufacturers to provide LAmB at affordable prices in Africa, more still needs to be done.
Accessible – We must urgently strengthen our healthcare systems to ensure that diagnostics and treatments reach even the most remote regions. Every person, whether in a village in Uganda or an urban slum in Nigeria, deserves access to the highest standard of care. African governments must act decisively by registering flucytosine and LAmB as essential medicines, ensuring they are available to those who need them most. Community leaders play a critical role in this fight; they must keep advocating for equitable healthcare and hold leaders accountable to extend medicine supply chains far beyond urban centers, reaching the millions whose lives depend on it.
Affordable – A practical way to make medicines more affordable is for countries and stakeholders to coordinate regionally through pooled procurement to promote competitive prices from manufacturers and suppliers. For example, The Global Fund's Pooled Procurement Mechanism negotiates costs and delivery terms on behalf of countries. This strategy recently reduced the price of TLD, a first-line HIV treatment, to under $45 per person per year, enabling resource-limited governments to expand access to vital HIV services. This demonstrates how collective action can drive equity in healthcare.
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Acceptable – Treatments must be available in formulations that are simple for communities and health workers to use. For instance, flucytosine currently requires it to be administered every six hours. Patients with cryptococcal meningitis are often unconscious when they arrive at the hospital, requiring healthcare staff to crush the tablets for administration via nasogastric tube -a method that has not been registered and that is very time-consuming. This is why my organization DNDi with our partners, including the pharmaceutical company Viatris, are developing a simpler version that requires only twice-daily dosage and can be administered via nasogastric tube.
Despite many efforts to improve the situation, there remains significant gaps including in the diagnosis of cryptococcal meningitis. Greater investment is needed to ensure diagnostics are also widely available, and to develop new, simplified treatments that are available at the primary healthcare level.
Access to diagnostics and treatments is not charity—it is justice. On this World AIDS Day, let us commit to taking the Rights path, ensuring no one is left behind in the fight against HIV.
