The impact of routine cryptococcal antigen screening on survival among HIV-infected individuals with advanced immunosuppression in Kenya.
OBJECTIVE
To test the hypothesis that a screening and treatment intervention for early cryptococcal infection would improve survival among HIV-infected individuals with low CD4 cell counts.


METHODS
Newly enrolled patients at Family AIDS Care and Education Services (FACES) in Kenya with CD4 ≤ 100 cells/μl were tested for serum cryptococcal antigen (sCrAg). Individuals with sCrAg titre ≥ 1:2 were treated with high-dose fluconazole. Cox proportional hazard models of Kaplan-Meier curves were used to compare survival among individuals with CD4 ≤ 100 cells/μl in the intervention and historical control groups.


RESULTS
The median age was 34 years [IQR: 29,41], 54% were female, and median CD4 was 43 cells/μl [IQR: 18,71]. Follow-up time was 1224 person-years. In the intervention group, 66% (514/782) were tested for sCrAg; of whom, 11% (59/514) were sCrAg positive. Mortality was 25% (196/782) in the intervention group and 25% (191/771) in the control group. There was no significant difference between the intervention and control group in overall survival [hazard ratio (HR): 1.1 (95%CI:0.9,1.3)] or three-month survival [HR: 1.0 (95%CI:0.8,1.3)]. Within the intervention group, sCrAg-positive individuals had significantly lower survival rates than sCrAg-negative individuals [HR:1.8 (95%CI: 1.0, 3.0)].


CONCLUSIONS
A screening and treatment intervention to identify sCrAg-positive individuals and treat them with high-dose fluconazole did not significantly improve overall survival among HIV-infected individuals with CD4 counts ≤ 100 cells/μl compared to a historical control, perhaps due to intervention uptake rates or poor efficacy of high-dose oral fluconazole.
Family AIDS Care and Education Services, Research Care and Training Program, Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya. anaclaire@gmail.com
A-C L
AC
Meyer
C K
CK
Kendi
J A
JA
Penner
N
N
Odhiambo
B
B
Otieno
E
E
Omondi
E
E
Opiyo
E A
EA
Bukusi
C R
CR
Cohen
D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy / Q000276:immunology / Q000401:mortality*; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D000946:Antigens, Fungal / Q000097:blood*; D018791:CD4 Lymphocyte Count; D016022:Case-Control Studies; D003455:Cryptococcus neoformans / Q000276:immunology*; D005260:Female; D015725:Fluconazole / Q000627:therapeutic use; D006801:Humans; D053208:Kaplan-Meier Estimate; D007630:Kenya; D008297:Male; D016919:Meningitis, Cryptococcal / Q000188:drug therapy / Q000276:immunology / Q000401:mortality*; D015996:Survival Rate; D016896:Treatment Outcome
D044966:Anti-Retroviral Agents; D000935:Antifungal Agents; D000946:Antigens, Fungal; D015725:Fluconazole