The impact of routine cryptococcal antigen screening on survival among HIV-infected individuals with advanced immunosuppression in Kenya.

Objectives 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 (s CrAg). Individuals with s CrAg 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 s CrAg; of whom, 11% (59/514) were s CrAg 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, s CrAg-positive individuals had significantly lower survival rates than s CrAg-negative individuals [ HR:1.8 (95% CI: 1.0, 3.0)]. Conclusions A screening and treatment intervention to identify s CrAg-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. [ABSTRACT FROM AUTHOR]