David B. Meya

David B. Meya; Yukari C. Manabe; Barbara Castelnuovo; Bethany Cook; Ali Elbireer; Andrew Kambugu; Moses R. Kamya; Paul R. Bohjanen; David R. Boulware

BACKGROUND Cryptococcal meningitis (CM) remains a common AIDS-defining illness in Africa and Asia. Subclinical cryptococcal antigenemia is frequently unmasked with antiretroviral therapy (ART). We sought to define the cost-effectiveness of serum cryptococcal antigen (CRAG) screening to identify persons with subclinical cryptococcosis and the efficacy of preemptive fluconazole therapy. METHODS There were 609 ART-naive adults with AIDS who started ART in Kampala, Uganda, and who had a serum CRAG prospectively measured during 2004-2006. The number needed to test and treat with a positive CRAG was assessed for > or = 30-month outcomes. RESULTS In the overall cohort, 50 persons (8.2%) were serum CRAG positive when starting ART. Of 295 people with a CD4(+) cell count < or = 100 cells/microL and without prior CM, 26 (8.8%; 95% confidence interval [CI], 5.8%-12.6%) were CRAG positive, of whom 21 were promptly treated with fluconazole (200-400 mg) for 2-4 weeks. Clinical CM developed in 3 fluconazole-treated persons, and 30-month survival was 71% (95% CI, 48%-89%). In the 5 CRAG-positive persons with a CD4(+) cell count < or = 100 cells/microL treated with ART but not fluconazole, all died within 2 months of ART initiation. The number needed to test and treat with CRAG screening and fluconazole to prevent 1 CM case is 11.3 (95% CI, 7.9-17.1) at costs of

David R. Boulware; David B. Meya; Tracy L. Bergemann; Darin L. Wiesner; Joshua Rhein; Abdu Musubire; Sarah J. Lee; Andrew Kambugu; Edward N. Janoff; Paul R. Bohjanen

190 (95% CI,

David R. Boulware; Shulamith C. Bonham; David B. Meya; Darin L. Wiesner; Gregory S. Park; Andrew Kambugu; Edward N. Janoff; Paul R. Bohjanen

132-

Radha Rajasingham; David B. Meya; David R. Boulware

287). The number needed to test and treat to save 1 life is 15.9 (95% CI, 11.1-24.0) at costs of

Joshua Rhein; Bozena M. Morawski; Katherine Huppler Hullsiek; Henry W. Nabeta; Reuben Kiggundu; Lillian Tugume; Abdu Musubire; Andrew Akampurira; Kyle D. Smith; Ali Alhadab; Darlisha A. Williams; Mahsa Abassi; Nathan C. Bahr; Sruti S Velamakanni; James Fisher; Kirsten Nielsen; David B. Meya; David R. Boulware

266 (95% CI,

Radha Rajasingham; Melissa A. Rolfes; Kate E. Birkenkamp; David B. Meya; David R. Boulware

185-

Emma J. Robertson; Grace Najjuka; Melissa A. Rolfes; Andrew Akampurira; Neena Jain; Janani Anantharanjit; Maximilian von Hohenberg; Manlio Tassieri; Allan Carlsson; David B. Meya; Thomas S. Harrison; Bettina C. Fries; David R. Boulware; Tihana Bicanic

402). The cost per disability-adjusted life year saved is

Kyle D. Smith; Beatrice Achan; Katherine Huppler Hullsiek; Tami R. McDonald; Laura H. Okagaki; Ali Alhadab; Andrew Akampurira; Joshua Rhein; David B. Meya; David R. Boulware; Kirsten Nielsen

21 (95% CI,

Darin L. Wiesner; Oleksandr Moskalenko; Jennifer Corcoran; Tami R. McDonald; Melissa A. Rolfes; David B. Meya; Henry Kajumbula; Andrew Kambugu; Paul R. Bohjanen; Joseph F. Knight; David R. Boulware; Kirsten Nielsen

15-

Joshua Rhein; Nathan C. Bahr; Andrew Hemmert; Joann L. Cloud; Satya Bellamkonda; Cody Oswald; Eric Lo; Henry W. Nabeta; Reuben Kiggundu; Andrew Akampurira; Abdu Musubire; Darlisha A. Williams; David B. Meya; David R. Boulware

32). CONCLUSIONS Integrating CRAG screening into HIV care, specifically targeting people with severe immunosuppression (CD4(+) cell count < or = 100 cells/microL) should be implemented in treatment programs in resource-limited settings. ART alone is insufficient treatment for CRAG-positive persons.