title: Implementation and Operational Research: Evaluation of a Public-Sector, Provider-Initiated Cryptococcal Antigen Screening and Treatment Program, Western Cape, South Africa.
abstract: Screening for serum cryptococcal antigen (CrAg) may identify those at risk for disseminated cryptococcal disease (DCD), and preemptive fluconazole treatment may prevent progression to DCD. In August 2012, the Western Cape Province (WC), South Africa, adopted provider-initiated CrAg screening. We evaluated the implementation and effectiveness of this large-scale public-sector program during its first year, September 1, 2012-August 31, 2013.
  
  
  
  We used data from the South African National Health Laboratory Service, WC provincial HIV program, and nationwide surveillance data for DCD. We assessed the proportion of eligible patients screened for CrAg (CrAg test done within 30 days of CD4 date) and the prevalence of CrAg positivity. Incidence of DCD among those screened was compared with those not screened.
  
  
  
  Of 4395 eligible patients, 26.6% (n = 1170) were screened. The proportion of patients screened increased from 15.9% in September 2012 to 36.6% in August 2013. The prevalence of positive serum CrAg was 2.1%. Treatment data were available for 13 of 24 CrAg-positive patients; 9 of 13 were treated with fluconazole. Nine (0.8%) incident cases of DCD occurred among the 1170 patients who were screened for CrAg vs. 49 (1.5%) incident cases among the 3225 patients not screened (P = 0.07).
  
  
  
  Relatively few eligible patients were screened under the WC provider-initiated CrAg screening program. Unscreened patients were nearly twice as likely to develop DCD. CrAg screening can reduce the burden of DCD, but needs to be implemented well. To improve screening rates, countries should consider laboratory-based reflexive screening when possible.
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA.|Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Snigdha
authors.initials: S
authors.lastname: Vallabhaneni
authors.affiliation: St. George's, University of London, London, UK.|Desmond Tutu HIV/AIDS Foundation, University of Cape Town, Cape Town, South Africa.
authors.forename: Nicky
authors.initials: N
authors.lastname: Longley
authors.affiliation: Centre for Infectious Diseases, Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Mariette
authors.initials: M
authors.lastname: Smith
authors.affiliation: Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors.forename: Rachel
authors.initials: R
authors.lastname: Smith
authors.affiliation: Centre for Infectious Diseases, Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Meg
authors.initials: M
authors.lastname: Osler
authors.affiliation: Desmond Tutu HIV/AIDS Foundation, University of Cape Town, Cape Town, South Africa.
authors.forename: Nicola
authors.initials: N
authors.lastname: Kelly
authors.affiliation: Desmond Tutu HIV/AIDS Foundation, University of Cape Town, Cape Town, South Africa.
authors.forename: Anna
authors.initials: A
authors.lastname: Cross
authors.affiliation: Centre for Infectious Diseases, Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.|Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa.|Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town.
authors.forename: Andrew
authors.initials: A
authors.lastname: Boulle
authors.affiliation: Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town.
authors.forename: Graeme
authors.initials: G
authors.lastname: Meintjes
authors.affiliation: National Institute for Communicable Diseases - Centre for Opportunistic, Tropical and Hospital Infections, a Division of the National Health Laboratory Service, Johannesburg, South Africa and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
authors.forename: Nelesh P
authors.initials: NP
authors.lastname: Govender
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology / Q000276:immunology; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use*; D000946:Antigens, Fungal / Q000032:analysis*; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology / Q000276:immunology; D006801:Humans; D008297:Male; D008403:Mass Screening; D016919:Meningitis, Cryptococcal / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control; D009874:Operations Research; D063868:Patient Outcome Assessment; D012189:Retrospective Studies; D013019:South Africa / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents; D000935:Antifungal Agents; D000946:Antigens, Fungal