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)|
|Number of pages||9|
|Journal||Journal of Acquired Immune Deficiency Syndromes|
|State||Published - Feb 1 2019|
Bibliographical noteFunding Information:
Supported by the Meningitis Research Foundation (MRF 1505) and the National Institute of Neurologic Diseases and Stroke (R01NS086312) and United Kingdom Medical Research Council (MR/M007413/1). The Chronic Diseases of Ifakara receives funding from the Government of Tanzania, the Government of the Canton of Basel, the Swiss Tropical and Public Health Institute, and the Ifakara Health Institute.
© 2018 Wolters Kluwer Health, Inc. All rights reserved.
- cryptococcal antigenemia
- cryptococcal meningitis
- sub-Saharan Africa
- Prospective Studies
- Middle Aged
- Antigens, Fungal/therapeutic use
- AIDS-Related Opportunistic Infections/diagnosis
- Meningitis, Cryptococcal/diagnosis
- Mass Screening
- HIV Infections/complications
- Fluconazole/therapeutic use
- Survival Analysis
- 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