The DREAMM project aims to sustainably reduce mortality linked to HIV-related meningo-encephalitis in routine care resource-limited settings in three African low and middle income countries (LMICs) - Tanzania, Cameroon, and Malawi

DREAMM

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A starting premise for the DREAMM project is independent African research leadership linking with hospital directors working in routine care services and their Ministry of Health counterparts.

DREAMM is an implementation project that uses a mixture of traditional clinical trial methodology combined with local health system strengthening, social science, education and health economics.

There are three phases to the project: 1) Observation, 2) Training and 3) Implementation.

The three DREAMM study sites will effectively work as test sites within country and region with collated health system process and epidemiological data informing local and regional public health policy.

  • Dates: April 2016 – ongoing
  • Principal Investigator: Angela Loyse
  • Locations: Tanzania, Cameroon and Malawi
  • Funding: EDCTP and ANRS

Why is DREAMM needed?

Mortality due to HIV-related meningo-encephalitis remains unacceptably high in resource limited settings in African LMICs.

This is due to a number of factors including:

  • Lack of access to rapid diagnostic tests (RDTs) and essential medicines such as amphotericin B and flucytosine
  • Breakdown of routine laboratory pathways
  • Poor communication between laboratory technicians and clinicians
  • Lack of specific training on diagnosis and management of HIV-related meningo-encephalitis

The main objectives of the observation phase of the DREAMM project are to document:

  • Time from patient presentation to appropriate diagnostic procedures including lumbar puncture (LP).
  • Time from patient presentation to treatment.
  • Two and ten week HIV-associated meningo-encephalitis patient mortality in each of the three study sites.
  • Availability of diagnostic tests, drugs and monitoring facilities for HIV-associated meningo-encephalitis in each of the three study sites.
  • Current HIV-associated meningo-encephalitis patient and laboratory pathways.
  • Current practices and procedures for patient specimen transport, laboratory test reporting and communication between clinicians and laboratory staff.

DREAMM interventions

Provision of the latest diagnostics and medicines
All DREAMM patients are tested using RDTs including the cryptococcal antigen lateral flow assay (CrAg LFA) and urinary lipoarabinomannan (LAM), alongside routine basic microbiological techniques. A new semi-quantitative CrAg LFA test developed between industry and Biosynex is being evaluated. Where tuberculous meningitis is suspected, Gene Xpert Ultra cartridges are used on both cerebrospinal fluid and urinary samples.

The DREAMM project implements the results of the ACTA trial, with patients diagnosed with cryptococcal meningitis receiving one week of amphotericin B and flucytosine as first line therapy, in line with 2018 WHO guidance. In many routine care settings in African LMICs fluconazole therapy for cryptococcal meningitis is the only available option with resulting unacceptable mortality.

Diagnostic and treatment algorithm
RDTs and essential medicines for the management of HIV-related meningo-encephalitis are nested within a diagnostic and treatment algorithm. The aim is for this algorithm together with optimised patient and laboratory pathways to become standard of care.

DREAMM education programme
The DREAMM education programme includes both laboratory and clinical modules. The laboratory training module is led by Mme Aude Sturny Leclère from Institut Pasteur and encompasses training on the latest RDTs and also refresher training on basic microbiological techniques for cerebrospinal fluid analysis (CSF). The clinical training modules include: 1) Educational resources in poster format, 2) Practical workshops focused on interventions for patients with HIV-related meningo-encephalitis that can reduce mortality and 3) Comprehensive theoretical slide sets on the diagnosis and management of the main causes of HIV-related meningo-encephalitis in African LMICs.

Laboratory capacity building and Advanced HIV disease/infectious diseases mentorship
Laboratory capacity building and advanced HIV disease/infectious diseases mentorship are two wedge-shaped interventions that form key parts of the implementation phase of DREAMM. Local laboratory capacity building includes fungal culture and routine biochemical analysis of CSF. Weekly pan-African clinical meetings provide a forum for practical learning on the diagnostic and training algorithm and the management of advanced HIV disease more generally.

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DREAMM collaborators and study site locations

DREAMM is currently ongoing at these sites in southern, eastern and central Africa:

  • Amana and Mwananyamala hospitals, Dar Es Salaam, Tanzania
  • Kamuzu Central Hospital (KCH), Lilongwe, Malawi
  • Hôpital Central Yaoundé (HCY), Yaoundé, Cameroon

The DREAMM project is in collaboration with the following partners:

  • National Institute for Medical Research, Tanzania
  • University of North Carolina Project-Malawi (UNC Project)
  • Yaoundé Central Hospital
  • Institut Pasteur

DREAMM education programme

The DREAMM education programme aims to increase the knowledge of HCWs to effectively diagnose and treat symptomatic people living with HIV (PLHIV) who present with symptoms and signs compatible with a diagnosis of meningo-encephalitis.

The comprehensive education programme includes in-depth modules, posters and workshops. All of the materials have been created in conjunction with African research and routine care staff within the DREAMM Project to ensure applicability of the training.

There are 6 training modules on:

  • General meningo-encephalitis patient management
  • Cryptococcal meningitis
  • Tuberculous meningitis
  • Bacterial meningitis
  • Toxoplasmic encephalitis
  • Neurosyphilis

Each topic is supported by a series of posters and workshops that are designed to be trained on in-person for routine HCWs working in resource limited African LMIC settings. The workshops have been designed to focus on simple and practical interventions that can reduce mortality (e.g. safe antifungal drug administration).



DREAMM Project advocacy

The DREAMM project includes advocacy work to improve access and procurement mechanisms in African LMICs for RDTs and essential medicines including flucytosine. Some of this work is encompassed by the work of the cryptcoccal meningitis action group (cryptoMAG) and advanced HIV disease consortium (ADC).


Last Updated: Tuesday, 30 April 2019 15:30