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The impact of routine cryptococcal antigen screening on survival among HIV ‐infected individuals with advanced immunosuppression in K enya
Author(s) -
Meyer A.C. L.,
Kendi C. K.,
Penner J. A.,
Odhiambo N.,
Otieno B.,
Omondi E.,
Opiyo E.,
Bukusi E. A.,
Cohen C. R.
Publication year - 2013
Publication title -
tropical medicine and international health
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.056
H-Index - 114
eISSN - 1365-3156
pISSN - 1360-2276
DOI - 10.1111/tmi.12067
Subject(s) - medicine , survival analysis , immunosuppression , hazard ratio , proportional hazards model , immunology , human immunodeficiency virus (hiv) , confidence interval
Objectives To test the hypothesis that a screening and treatment intervention for early cryptococcal infection would improve survival among HIV ‐infected individuals with low CD 4 cell counts. Methods Newly enrolled patients at F amily AIDS C are and E ducation S ervices ( FACES ) in K enya with CD 4 ≤ 100 cells/μl were tested for serum cryptococcal antigen (s CrA g). Individuals with s CrA g titre ≥ 1:2 were treated with high‐dose fluconazole. Cox proportional hazard models of K aplan– M eier curves were used to compare survival among individuals with CD 4 ≤ 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 CD 4 was 43 cells/μl [ IQR : 18,71]. Follow‐up time was 1224 person‐years. In the intervention group, 66% (514/782) were tested for s CrA g; of whom, 11% (59/514) were s CrA g 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 [ h azard r atio ( 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, s CrA g‐positive individuals had significantly lower survival rates than s CrA g‐negative individuals [ HR :1.8 (95% CI : 1.0, 3.0)]. Conclusions A screening and treatment intervention to identify s CrA g‐positive individuals and treat them with high‐dose fluconazole did not significantly improve overall survival among HIV ‐infected individuals with CD 4 counts ≤ 100 cells/μl compared to a historical control, perhaps due to intervention uptake rates or poor efficacy of high‐dose oral fluconazole.