title: Cost-effectiveness of primary prophylaxis of AIDS associated cryptococcosis in Cambodia.
abstract: BACKGROUND
  Cryptococcal infection is a frequent cause of mortality in Cambodian HIV-infected patients with CD4+ count ≤100 cells/µl. This study assessed the cost-effectiveness of three strategies for cryptococcosis prevention in HIV-infected patients.
  
  
  METHODS
  A MARKOV DECISION TREE WAS USED TO COMPARE THE FOLLOWING STRATEGIES AT THE TIME OF HIV DIAGNOSIS: no intervention, one time systematic serum cryptococcal antigen (CRAG) screening and treatment of positive patients, and systematic primary prophylaxis with fluconazole. The trajectory of a hypothetical cohort of HIV-infected patients with CD4+ count ≤100 cells/µl initiating care was simulated over a 1-year period (cotrimoxazole initiation at enrollment; antiretroviral therapy within 3 months). Natural history and cost data (US$ 2009) were from Cambodia. Efficacy data were from international literature.
  
  
  RESULTS
  In a population in which 81% of patients had a CD4+ count ≤50 cells/ µl and 19% a CD4+ count between 51-100 cells/µl, the proportion alive 1 year after enrollment was 61% (cost $ 472) with no intervention, 70% (cost $ 483) with screening, and 72% (cost $ 492) with prophylaxis. After one year of follow-up, the cost-effectiveness of screening vs. no intervention was US$ 180/life year gained (LYG). The cost-effectiveness of prophylaxis vs. screening was $ 511/LYG. The cost-effectiveness of prophylaxis vs. screening was estimated at $1538/LYG if the proportion of patients with CD4+ count ≤50 cells/µl decreased by 75%.
  
  
  CONCLUSIONS
  In a high endemic area of cryptococcosis and HIV infection, serum CRAG screening and prophylaxis are two cost effective strategies to prevent AIDS associated cryptococcosis in patients with CD4+ count ≤100 cells/µl, at a short-term horizon, screening being more cost-effective but less effective than prophylaxis. Systematic primary prophylaxis may be preferred in patients with CD4+ below 50 cells/µl while systematic serum CRAG screening for early targeted treatment may be preferred in patients with CD4+ between 51-100 cells/µl.
authors.affiliation: Unité d'Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France. romain.micol@gmail.com
authors.forename: Romain
authors.initials: R
authors.lastname: Micol
authors.forename: Ayden
authors.initials: A
authors.lastname: Tajahmady
authors.forename: Olivier
authors.initials: O
authors.lastname: Lortholary
authors.forename: Suna
authors.initials: S
authors.lastname: Balkan
authors.forename: Catherine
authors.initials: C
authors.lastname: Quillet
authors.forename: Jean-Philippe
authors.initials: JP
authors.lastname: Dousset
authors.forename: Hak
authors.initials: H
authors.lastname: Chanroeun
authors.forename: Yoann
authors.initials: Y
authors.lastname: Madec
authors.forename: Arnaud
authors.initials: A
authors.lastname: Fontanet
authors.forename: Yazdan
authors.initials: Y
authors.lastname: Yazdanpanah
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000517:prevention & control*; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D000935:Antifungal Agents / Q000191:economics / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D002160:Cambodia; D003362:Cost-Benefit Analysis; D003453:Cryptococcosis / Q000209:etiology / Q000382:microbiology / Q000517:prevention & control*; D015725:Fluconazole / Q000191:economics / Q000627:therapeutic use*; D005500:Follow-Up Studies; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy; D006801:Humans; D008390:Markov Chains; D016896:Treatment Outcome; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000191:economics / Q000627:therapeutic use
chemical_list: D044966:Anti-Retroviral Agents; D000935:Antifungal Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D015725:Fluconazole