Abstract
BACKGROUND: Cryptococcal antigen (CrAg) screening in persons with advanced HIV/AIDS is recommended to prevent death. Implementing CrAg screening only in outpatients may underestimate the true CrAg prevalence and decrease its potential impact. Our previous 12-month survival/retention in CrAg-positive persons not treated with fluconazole was 0%.
METHODS: HIV testing was offered to all antiretroviral therapy-naive outpatients and hospitalized patients in Ifakara, Tanzania, followed by laboratory-reflex CrAg screening for CD4 <150 cells/μL. CrAg-positive individuals were offered lumbar punctures, and antifungals were tailored to the presence/absence of meningitis. We assessed the impact on survival and retention-in-care using multivariate Cox-regression models.
RESULTS: We screened 560 individuals for CrAg. The median CD4 count was 61 cells/μL (interquartile range 26-103). CrAg prevalence was 6.1% (34/560) among individuals with CD4 ≤150 and 7.5% among ≤100 cells/μL. CrAg prevalence was 2.3-fold higher among hospitalized participants than in outpatients (12% vs 5.3%, P = 0.02). We performed lumbar punctures in 94% (32/34), and 31% (10/34) had cryptococcal meningitis. Mortality did not differ significantly between treated CrAg-positive without meningitis and CrAg-negative individuals (7.3 vs 5.4 deaths per 100 person-years, respectively, P = 0.25). Independent predictors of 6-month death/lost to follow-up were low CD4, cryptococcal meningitis (adjusted hazard ratio 2.76, 95% confidence interval: 1.31 to 5.82), and no antiretroviral therapy initiation (adjusted hazard ratio 3.12, 95% confidence interval: 2.16 to 4.50).
CONCLUSIONS: Implementing laboratory-reflex CrAg screening among outpatients and hospitalized individuals resulted in a rapid detection of cryptococcosis and a survival benefit. These results provide a model of a feasible, effective, and scalable CrAg screening and treatment strategy integrated into routine care in sub-Saharan Africa.
Original language | English (US) |
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Pages (from-to) | 205-213 |
Number of pages | 9 |
Journal | Journal of Acquired Immune Deficiency Syndromes |
Volume | 80 |
Issue number | 2 |
DOIs | |
State | Published - Feb 1 2019 |
Bibliographical note
Publisher Copyright:© 2018 Wolters Kluwer Health, Inc. All rights reserved.
Keywords
- HIV
- cryptococcal antigenemia
- cryptococcal meningitis
- fluconazole
- mortality
- sub-Saharan Africa
- Tanzania/epidemiology
- Prevalence
- Prospective Studies
- Humans
- Middle Aged
- Antigens, Fungal/therapeutic use
- Male
- AIDS-Related Opportunistic Infections/diagnosis
- Meningitis, Cryptococcal/diagnosis
- Mass Screening
- HIV Infections/complications
- Fluconazole/therapeutic use
- Survival Analysis
- Adult
- Female
- Antifungal Agents/therapeutic use
- Longitudinal Studies
PubMed: MeSH publication types
- Research Support, Non-U.S. Gov't
- Journal Article
- Research Support, N.I.H., Extramural