Laboratory-reflex cryptococcal antigen screening is associated with a survival benefit in Tanzania.

Faini, Diana; Kalinjuma, Aneth Vedastus; Katende, Andrew; Mbwaji, Gladys; Mnzava, Dorcas; Nyuri, Amina; Glass, Tracy R; Furrer, Hansjakob; Hatz, Christoph; Boulware, David R; Letang, Emilio (2019). Laboratory-reflex cryptococcal antigen screening is associated with a survival benefit in Tanzania. Journal of acquired immune deficiency syndromes JAIDS, 80(2), pp. 205-213. Lippincott Williams & Wilkins 10.1097/QAI.0000000000001899

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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 ART-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 (IQR 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 persons-year, respectively, p=0.25). Independent predictors of 6-month death/lost to follow-up were low CD4, cryptococcal meningitis (adjusted hazard ratio (aHR) 2.76, 95% CI 1.31-5.82)), and no ART initiation (aHR 3.12, 95%CI 2.16-4.50). 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.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC) , where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of Haematology, Oncology, Infectious Diseases, Laboratory Medicine and Hospital Pharmacy (DOLS) > Clinic of Infectiology

UniBE Contributor:

Furrer, Hansjakob

Subjects:

600 Technology > 610 Medicine & health

ISSN:

0894-9255

Publisher:

Lippincott Williams & Wilkins

Language:

English

Submitter:

Annelies Luginbühl

Date Deposited:

31 Jan 2019 13:38

Last Modified:

31 Jan 2019 14:39

Publisher DOI:

10.1097/QAI.0000000000001899

PubMed ID:

30422904

BORIS DOI:

10.7892/boris.121421

URI:

https://boris.unibe.ch/id/eprint/121421

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