Journal Article

Cost-Effectiveness of Serum Cryptococcal Antigen Screening to Prevent Deaths among HIV-Infected Persons with a CD4<sup>+</sup> Cell Count ≤100 Cells/<i>μ</i>L Who Start HIV Therapy in Resource-Limited Settings

David B. Meya, Yukari C. Manabe, Barbara Castelnuovo, Bethany A. Cook, Ali M. Elbireer, Andrew Kambugu, Moses R. Kamya, Paul R. Bohjanen and David R. Boulware

in Clinical Infectious Diseases

Published on behalf of Infectious Diseases Society of America

Volume 51, issue 4, pages 448-455
Published in print August 2010 | ISSN: 1058-4838
Published online August 2010 | e-ISSN: 1537-6591 | DOI: http://dx.doi.org/10.1086/655143
Cost-Effectiveness of Serum Cryptococcal Antigen Screening to Prevent Deaths among HIV-Infected Persons with a CD4+ Cell Count ≤100 Cells/μL Who Start HIV Therapy in Resource-Limited Settings

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Background. Cryptococcal meningitis (CM) remains a common AIDS-defining illness in Africa and Asia. Subclinical cryptococcal antigenemia is frequently unmasked with antiretroviral therapy (ART). We sought to define the cost-effectiveness of serum cryptococcal antigen (CRAG) screening to identify persons with subclinical cryptococcosis and the efficacy of preemptive fluconazole therapy.

Methods. There were 609 ART-naive adults with AIDS who started ART in Kampala, Uganda, and who had a serum CRAG prospectively measured during 2004–2006. The number needed to test and treat with a positive CRAG was assessed for ≥30-month outcomes.

Results. In the overall cohort, 50 persons (8.2%) were serum CRAG positive when starting ART. Of 295 people with a CD4+ cell count ≤100 cells/μL and without prior CM, 26 (8.8%; 95% confidence interval [CI], 5.8%–12.6%) were CRAG positive, of whom 21 were promptly treated with fluconazole (200–400 mg) for 2–4 weeks. Clinical CM developed in 3 fluconazole-treated persons, and 30-month survival was 71% (95% CI, 48%–89%). In the 5 CRAG-positive persons with a CD4+ cell count ≤100 cells/μL treated with ART but not fluconazole, all died within 2 months of ART initiation. The number needed to test and treat with CRAG screening and fluconazole to prevent 1 CM case is 11.3 (95% CI, 7.9–17.1) at costs of $190 (95% CI, $132–$287). The number needed to test and treat to save 1 life is 15.9 (95% CI, 11.1–24.0) at costs of $266 (95% CI, $185–$402). The cost per disability-adjusted life year saved is $21 (95% CI, $15–$32).

Conclusions. Integrating CRAG screening into HIV care, specifically targeting people with severe immunosuppression (CD4+ cell count ≤100 cells/μL) should be implemented in treatment programs in resource-limited settings. ART alone is insufficient treatment for CRAG-positive persons.

Journal Article.  4553 words.  Illustrated.

Subjects: Infectious Diseases ; Immunology ; Public Health and Epidemiology ; Microbiology

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