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Paccoud O, Shuping L, Mashau R, Greene G, Quan V, Meiring S, Govender NP. Impact of prior cryptococcal antigen screening on in-hospital mortality in cryptococcal meningitis or fungaemia among HIV-seropositive individuals in South Africa: a cross-sectional observational study. Clin Microbiol Infect 2023; 29:1063-1069. [PMID: 37086780 DOI: 10.1016/j.cmi.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVES We investigated whether patients with cryptococcal meningitis (CM) or fungaemia detected through South Africa's laboratory cryptococcal antigen (CrAg) screening programme had better outcomes than those presenting directly to the hospital. METHODS We compared 14-day in-hospital case-fatality ratios of HIV-seropositive individuals with CD4 counts below 100 cells/μL and laboratory-confirmed CM/fungaemia from 2017-2021, with or without evidence of a positive blood CrAg test within 14 days prior to diagnosis. We evaluated whether the impact of prior CrAg screening on mortality varied according to the study period (pre-COVID-19: before March 2020 vs. COVID-19: after March 2020). RESULTS Overall, 24.5% (830/3390) of patients had a prior positive CrAg test within 14 days of diagnosis. CrAg-screened patients were less likely to have an altered mental status at baseline than non-CrAg-screened patients (38.1% [296/776] vs. 42.6% [1010/2372], p = 0.03), and had a lower crude 14-day case-fatality ratio (24.7% [205/830] vs. 28.3% [724/2560]; OR, 0.83 [95% CI, 0.69-0.99]; p = 0.045). Previous CrAg screening was associated with a greater reduction in the crude 14-day mortality during the COVID-19 period (OR, 0.64 [0.47-0.87]; p = 0.005) compared with before (OR, 0.95 [0.76-1.19]; p = 0.68). After adjustment, previous CrAg screening within 14 days was associated with increased survival only during the COVID-19 period (adjusted OR, 0.70 [0.51-0.96]; p = 0.03). DISCUSSION Previous CrAg screening was associated with a survival benefit in patients hospitalized with CM/fungaemia during the COVID-19 period, with fewer patients having an altered mental status at baseline, suggesting that these patients may have been diagnosed with cryptococcosis earlier.
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Affiliation(s)
- Olivier Paccoud
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; Université Paris Cité, Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Hospital Necker-Enfants Maladies, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Liliwe Shuping
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Rudzani Mashau
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Greg Greene
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Vanessa Quan
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Susan Meiring
- Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nelesh P Govender
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Institute of Infection and Immunity, St George's University of London, London, UK; Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, UK; Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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Gagnon KW, Levy S, Figge C, Wolford Clevenger C, Murray L, Kane JC, Bosomprah S, Sharma A, Nghiem VTH, Chitambi C, Vinikoor M, Eaton E, Cropsey K. Telemedicine for unhealthy alcohol use in adults living with HIV in Alabama using common elements treatment approach: A hybrid clinical efficacy-implementation trial protocol. Contemp Clin Trials Commun 2023; 33:101123. [PMID: 37063165 PMCID: PMC10090240 DOI: 10.1016/j.conctc.2023.101123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 04/03/2023] Open
Abstract
Background Unhealthy alcohol use is an unaddressed barrier to achieving and maintaining control of the human immunodeficiency virus (HIV) epidemic. Integrated screening, treatment of common behavioral and mental health comorbidities, and telemedicine can improve alcohol treatment and HIV clinical and quality of life outcomes for rural and underserved populations. Objective In a randomized controlled clinical trial, we will evaluate the effectiveness and implementation of telephone-delivered Common Elements Treatment Approach (T-CETA), a transdiagnostic cognitive behavioral therapy protocol, on unhealthy alcohol use, HIV, other substance use and mental health outcomes among predominantly rural adults with HIV receiving care at community clinics in Alabama. Methods Adults with HIV receiving care at four selected community clinics in Alabama will receive a telephone-delivered alcohol brief intervention (BI), and then be assigned at random (stratified by clinic and sex) to no further intervention or T-CETA. Participants will be recruited after screening positively for unhealthy alcohol use or when referred by a provider. The target sample size is 308. The primary outcome will be change in the Alcohol Use Disorder Identification Test (AUDIT) at six- and 12-months post-enrollment. Additional outcomes include HIV (retention in care and viral suppression), patient-reported mental health (anxiety, depression, posttraumatic stress), and quality of life. A range of implementation measures be evaluated including T-CETA provider and client acceptability, feasibility, cost and cost-effectiveness. Conclusions This trial will inform alcohol treatment within HIV care programs, including the need to consider comorbidities, and the potential impact of alcohol interventions on HIV and quality of life outcomes.
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Srishyla D, Saemisch G, Turya F, Nalintya E, Jjunju S, Kagimu E, Rutakingirwa MK, Skipper CP, Boulware DR, Meya DB, Rajasingham R. Determinants of cryptococcal antigen (CrAg) screening uptake in Kampala, Uganda: An assessment of health center characteristics. Med Mycol 2022; 60:myac013. [PMID: 35353190 PMCID: PMC8973400 DOI: 10.1093/mmy/myac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Cryptococcal antigen (CrAg) screening and pre-emptive antifungal therapy for people with CD4 cell counts <100 cells/μl are recommended by the World Health Organization and several national HIV guidelines. We sought to evaluate CrAg screening program implementation across Uganda, in relation to health center level and distance from the capital. We conducted a cross-sectional study of 22 health centers across southern Uganda from April to June 2019. We reviewed laboratory records regarding number of CD4 cell count tests performed, proportion of outpatients with CD4 counts <200 cells/μl, and number of CrAg screening tests performed. We administered surveys to health center staff to understand barriers to advanced HIV care. We observed no significant difference in health center level and performance of CrAg screening; with each subsequent health center level, there was 1.17-fold (95% CI: 0.92-1.41) higher odds of CrAg screening performed per level. CrAg screening uptake was not associated with distance from the capital city (odds ratio = 0.96, 95% CI: 0.89-1.04). Qualitative data from surveys indicated that limitations to uptake of CrAg screening were secondary to dysfunctional CD4 machines, lack of provider awareness of CrAg screening guidelines, and inadequate/intermittent supply of CrAg tests. There were no significant associations between CrAg screening uptake and level of health center or distance of health center from the capital city. We identified systemic barriers to CrAg screening related to inadequate CD4 testing, insufficient knowledge regarding national screening guidelines, and irregular laboratory testing supplies. LAY SUMMARY The objective of this study was to evaluate cryptococcal antigen (CrAg) screening program implementation in Uganda, by type of healthcare center and by distance from the capital city. CrAg screening uptake was not associated with distance from the capital city, or the type of healthcare center.
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Affiliation(s)
- Diksha Srishyla
- Department of Medicine, University of Minnesota, Minneapolis, 55455, MN, USA
| | - Gabriel Saemisch
- Department of Medicine, University of Minnesota, Minneapolis, 55455, MN, USA
| | - Fred Turya
- Infectious Diseases Institute, Kampala, Uganda
| | | | | | | | | | - Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, 55455, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, 55455, MN, USA
| | | | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, 55455, MN, USA
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Huang SH, Lee CY, Tsai CS, Tsai MS, Liu CE, Hsu WT, Chen HA, Liu WD, Yang CJ, Sun HY, Ko WC, Lu PL, Lee YT, Hung CC. Screening for Cryptococcal Antigenemia and Burden of Cryptococcosis at the Time of HIV Diagnosis: A Retrospective Multicenter Study. Infect Dis Ther 2021; 10:1363-1377. [PMID: 34057690 PMCID: PMC8322196 DOI: 10.1007/s40121-021-00451-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/22/2021] [Indexed: 11/06/2022] Open
Abstract
Introduction Screening for cryptococcal antigen (CrAg) is recommended for people living with HIV (PLWH) who present with low CD4 lymphocyte counts. Real-world experience is important to identify gaps between the guidelines and clinical practice. We investigated the trends of CrAg testing and prevalence of cryptococcal antigenemia among PLWH at the time of HIV diagnosis and the related mortality in Taiwan from 2009 to 2018. Methods Medical records of newly diagnosed PLWH seeking care at six medical centers around Taiwan between 2009 and 2018 were reviewed. The annual trends of PLWH who had CrAg testing and cryptococcal antigenemia were examined by Cochran-Armitage test. Among PLWH with CD4 < 200 cells/µl, timing of CrAg testing was analyzed for association with 12-month all-cause mortality in Kaplan-Meier plots and in a Cox proportional hazards model after adjustments. Results Among 5372 included PLWH, 1150 (21.4%) presented with baseline CD4 < 100 cells/µl, and this proportion had decreased during the study period [from 108 (29.3%) in 2009 to 93 (22.3%) in 2018 (P = 0.039)]. The overall prevalence of cryptococcal antigenemia was 7.8% among PLWH with CD4 < 100 cells/µl, which remained stable during the 10-year study period (P = 0.356) and was 2.6% among PLWH with CD4 100–199 cells/µl. The uptake of CrAg testing had increased from 65.7% in 2009 to 78.0% in 2018 (P = 0.002) among PLWH with CD4 < 100 cells/µl. Late CrAg testing, defined by 14 days or later after HIV diagnosis, was associated with increased risk of 12-month mortality compared to early CrAg testing (adjusted hazard ratio 2.028, 95% CI 1.109–3.708). Conclusions Burden of cryptococcosis remained high among PLWH with low CD4 lymphocyte counts in Taiwan. Uptake of CrAg screening among late HIV presenters was still suboptimal and delayed. Late CrAg testing was associated with a higher mortality. Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00451-5.
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Affiliation(s)
- Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chun-Yuan Lee
- Department of Internal Medicine, Kaohsiung Medical University Hospital and College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chin-Shiang Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mao-Song Tsai
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chun-Eng Liu
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Wei-Ting Hsu
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Douliu, Yun-Lin County, Taiwan
| | - Hong-An Chen
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Wang-Da Liu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Chung-Shan South Road, Taipei, Taiwan.,Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Chia-Jui Yang
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Chung-Shan South Road, Taipei, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Liang Lu
- Department of Internal Medicine, Kaohsiung Medical University Hospital and College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yuan-Ti Lee
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chien-Ching Hung
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan. .,Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Chung-Shan South Road, Taipei, Taiwan. .,Department of Medical Research, China Medical University Hospital, Taichung, Taiwan. .,China Medical University, Taichung, Taiwan.
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Zuniga-Moya JC, Romero-Reyes LE, Saavedra EB, Montoya S, Varela D, Borjas M, Cerna A, Bejarano S, Martinez P, Lujan K, Erazo K, Lainez I, Pineda L, Yanes D, O'Halloran JA, Spec A. Prevalence of Cryptococcal Antigen and Outcomes in People With Human Immunodeficiency Virus in Honduras: A Cohort Study. Open Forum Infect Dis 2020; 8:ofaa557. [PMID: 33447630 PMCID: PMC7794649 DOI: 10.1093/ofid/ofaa557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/06/2020] [Indexed: 11/12/2022] Open
Abstract
Background Cryptococcal meningitis is a major cause of death among people with human immunodeficiency virus (PWH). Cryptococcal antigen (CrAg) testing of asymptomatic patients is an important public health measure to reduce mortality in high-incidence areas. However, limited data exist on CrAg prevalence in Central America. Methods We conducted a prospective cohort study at the 2 largest human immunodeficiency virus (HIV) clinics and hospitals in Honduras. Cryptococcal antigen in serum and cerebrospinal fluid was performed in individuals with HIV who had CD4 ≤100 cells/mm3 between 2017 and 2018. After CrAg testing, individuals were observed for 12 months to assess mortality using adjusted Cox proportional hazard models. Results A total of 220 PWH were tested for CrAg, 12.7% (n = 28) of which tested positive. Cryptococcal antigen prevalence was higher among hospitalized individuals in 40% (n = 10 of 25) of the cases. The proportion (35.8%) of individuals taking antiretroviral therapy was significantly (P < .01) lower among those who tested positive for CrAg. Overall mortality among the cohort was 11.4% (n = 25 of 220) by 12 months. Cryptococcal antigen-positive cases were at a significantly higher risk of death (adjusted hazard ratio, 2.69; 95% confidence interval, 1.07-6.84) compared with CrAg-negative participants. Conclusions Cryptococcal antigen prevalence in Honduras was high among PWH. Moreover, individuals who tested positive for CrAg testing were at a higher risk of death. Systemic CrAg of PWH with a CD4 ≤100 cells/mm3 should be routinely performed in Central America.
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Affiliation(s)
- Julio C Zuniga-Moya
- Universidad Catolica de Honduras Campus San Pedro Sula Pablo, San Pedro Sula, Honduras
| | | | | | | | - Diana Varela
- Hospital Escuela Universitario, Tegucigalpa, Honduras
| | | | - Alicia Cerna
- Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Suyapa Bejarano
- Universidad Catolica de Honduras Campus San Pedro Sula Pablo, San Pedro Sula, Honduras
| | - Paola Martinez
- Universidad Catolica de Honduras Campus San Pedro Sula Pablo, San Pedro Sula, Honduras
| | - Karen Lujan
- Clinica de Servicios de Atencion Integral, Tegucigalpa, Honduras
| | - Karen Erazo
- Clinica de Servicios de Atencion Integral, Tegucigalpa, Honduras
| | - Isis Lainez
- Hospital Dr. Mario Catarino Rivas, San Pedro Sula, Honduras
| | | | - David Yanes
- Universidad Catolica de Honduras Campus San Pedro Sula Pablo, San Pedro Sula, Honduras
| | - Jane A O'Halloran
- Department of Medicine, Division of Infection, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Andrej Spec
- Department of Medicine, Division of Infection, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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Sun F, Xu XL, Lu YQ, Chen YK. A study for precision diagnosing and treatment strategies in difficult-to-treat AIDS cases and HIV-infected patients with highly fatal or highly disabling opportunistic infections: Study protocol for the optimal early intervention for cryptococcal antigenemia in HIV-infected patients. Medicine (Baltimore) 2020; 99:e22874. [PMID: 33126335 PMCID: PMC7598873 DOI: 10.1097/md.0000000000022874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Asymptomatic cryptococcal antigenemia is a state of cryptococcal infection commonly seen in immunocompromised HIV-infected persons. Without early intervention, a proportion of HIV-infected persons with cryptococcal antigenemia may go on to develop cryptococcosis, especially cryptococcal meningitis, which is associated with high mortality. The benefits of antifungal intervention and optimal therapeutic intervention regimens for HIV-infected persons with cryptococcal antigenemia remain controversial. We therefore designed the present study in order to investigate the necessity of, and the optimal regimens for antifungal intervention in the clinical management of cryptococcal antigenemia in HIV-infected populations. METHODS/DESIGN This study will be an open-labeled, multi-center, prospective, randomized controlled trial, and 450 eligible participants will be randomized into a control arm and 2 intervention arms at a 1:1:1 ratio, with 150 subjects in each arm. Participants in the control arm will not receive antifungal treatment during the study period. Participants in intervention arm 1 will receive oral fluconazole 800 mg/day for 2 weeks, followed by 400 mg/day for 8 weeks and 200 mg/day for 42 weeks, and participants in intervention arm 2 will receive oral fluconazole 400 mg/day for 52 weeks. The primary outcome is the incidence of CM among the 3 groups during the study period. The secondary outcomes include the differences in all-cause mortality, proportion of patients reverting to blood CrAg negativity, change of CrAg titers, and adverse events among the 3 groups during the follow-up period. DISCUSSION We envisage that the results of this study will reveal the necessity of, and the optimal therapeutic regimens for, antifungal intervention in clinical management of HIV-infected patients with cryptococcal antigenemia. TRIAL REGISTRATION The study was registered as one of the 12 clinical trials under a general project at the Chinese Clinical Trial Registry on February 1, 2019, and the registration number of the general project is ChiCTR1900021195.
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Walker SM, Cox E, Revill P, Musiime V, Bwakura‐Dangarembizi M, Mallewa J, Cheruiyot P, Maitland K, Ford N, Gibb DM, Walker AS, Soares M. The cost-effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa. J Int AIDS Soc 2020; 23:e25469. [PMID: 32219991 PMCID: PMC7099175 DOI: 10.1002/jia2.25469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 01/14/2020] [Accepted: 02/06/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Many HIV-positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced-prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3 . We investigated the cost-effectiveness of this enhanced-prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count. METHODS The REALITY trial enrolled from June 2013 to April 2015. A decision-analytic model was developed to estimate the cost-effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard-prophylaxis, enhanced-prophylaxis, standard-prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced-prophylaxis (CrAg-positive) or standard-prophylaxis (CrAg-negative), the second to enhanced-prophylaxis (CrAg-positive) or enhanced-prophylaxis without fluconazole (CrAg-negative) and the third to standard-prophylaxis with fluconazole (CrAg-positive) or without fluconazole (CrAg-negative). The model estimated costs, life-years and quality-adjusted life-years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause. RESULTS Enhanced-prophylaxis was cost-effective at cost-effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost-effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhanced-prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US$722 per QALY). Results were sensitive to prices of the enhanced-prophylaxis components. Enhanced-prophylaxis was more effective and less costly than all CrAg testing strategies as enhanced-prophylaxis still conveyed health gains in CrAg-negative patients and savings from targeting prophylaxis based on CrAg status did not compensate for costs of CrAg testing. CrAg testing strategies did not become cost-effective unless the price of CrAg testing fell below US$2.30. CONCLUSIONS The REALITY enhanced-prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost-effective. Efforts should continue to ensure that components are accessed at lowest available prices.
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Affiliation(s)
| | - Edward Cox
- Centre for Health EconomicsUniversity of YorkYorkUK
| | - Paul Revill
- Centre for Health EconomicsUniversity of YorkYorkUK
| | | | | | - Jane Mallewa
- College of MedicineUniversity of Malawi and Malawi‐Liverpool‐Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
| | | | - Kathryn Maitland
- KEMRI Wellcome Trust Research ProgrammeKilifiKenya
- Department of Infectious DiseasesImperial CollegeLondonUK
| | - Nathan Ford
- HIV/AIDS Department and Global Hepatitis ProgrammeWorld Health OrganizationGenevaSwitzerland
| | | | | | - Marta Soares
- Centre for Health EconomicsUniversity of YorkYorkUK
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