Prevalence and Sequelae of Cryptococcal Antigenemia in Antiretroviral Therapy-experienced Populations: An Evaluation of Reflex Cryptococcal Antigen Screening in Botswana.
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Author list: Hurt WJ, Tenforde MW, Molefi M, Mitchell HK, Milton T, Azama MS, Goercke I, Mulenga F, Tlhako N, Tsholo K, Srivastava T, Leeme TB, Simoonga G, Muthoga C, Lechiile K, Mine M, Jarvis JN
Publication year: 2020
Journal acronym: Clin Infect Dis
ISSN: 1058-4838
eISSN: 1537-6591
Languages: English-Great Britain (EN-GB)
Abstract
BACKGROUND\nMETHODS\nRESULTS\nCONCLUSIONS\nEvidence to inform cryptococcal antigen (CrAg)-screening guidelines among antiretroviral therapy (ART)-experienced populations are lacking. We performed a study evaluating the utility of reflex CrAg-screening in Gaborone, Botswana.\nCD4 count data were collected from samples tested at the HIV reference laboratory from 2014-2016. CrAg screening was performed on samples with CD4 ≤100 cells/µL beginning January 2015. The proportion of CD4 counts ≤100 cells/µL was determined and the frequency and utility of repeat CrAg-testing described. Analyses were performed to ascertain the impact of ART-status on CrAg-prevalence and outcomes, and whether baseline CrAg titers could be used for risk stratification.\nOverall, 5.6% (3,335/59,300) of individuals tested had a CD4 ≤100 cells/μL; 2,108 samples with CD4 ≤100 cells/μl from 1,645 unique patients were CrAg-tested. Over half of samples were from ART-experienced individuals: 40.9% (863) on ART, and 12.1% (255) defaulters; 22% (463) of CrAg tests were on repeat samples. CrAg-prevalence was 4.8% (72/1,494, 95%CI:3.8-6.0%) among outpatients and 21.9% (32/151, 95%CI:15.3-28.5%) among inpatients. CrAg-prevalence rates did not differ significantly by ART-status, but 6-month mortality was significantly lower in CrAg-positive individuals on ART at screening. Ten new CrAg-positives were identified through repeat testing. A CrAg titer cut-point of ≥1:80 provided the best discrimination for 6-month survival.\nCrAg-positivity rates in an ART-experienced population were comparable to those seen in ART-naïve populations. Repeat screening identified individuals who seroconverted to CrAg-positivity and were at risk of cryptococcal disease. CrAg titers ≥1:80 can help identify the individuals at highest risk of death for more intensive management.
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