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

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 per...

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Bibliographic Details
Published in:Clinical infectious diseases 2010-08, Vol.51 (4), p.448-455
Main Authors: Meya, David B., Manabe, Yukari C., Castelnuovo, Barbara, Cook, Bethany A., Elbireer, Ali M., Kambugu, Andrew, Kamya, Moses R., Bohjanen, Paul R., Boulware, David R.
Format: Article
Language:English
Subjects:
AIDS
Antigens
Antiretrovirals
Biological and medical sciences
Cost control
Cost estimates
Cryptococcal meningitis
Fixed costs
HIV
HIV/AIDS
Human mycoses
Human viral diseases
Immunodeficiencies
Immunodeficiencies. Immunoglobulinopathies
Immunopathology
Infectious diseases
Medical sciences
Miscellaneous mycoses
Mortality
Mycoses
Viral diseases
Viral diseases of the lymphoid tissue and the blood. Aids
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Summary: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.
ISSN:1058-4838
1537-6591
DOI:10.1086/655143