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/
mL. 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/mL (interquartile range 26–103). CrAg prevalence
was 6.1% (34/560) among individuals with CD4 #150 and 7.5%
among #100 cells/mL. 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.
