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Cost Effectiveness of Cryptococcal Antigen Screening as a Strategy to Prevent HIV-Associated Cryptococcal Meningitis in South Africa.

Jarvis, JN; Harrison, TS; Lawn, SD; Meintjes, G; Wood, R; Cleary, S (2013) Cost Effectiveness of Cryptococcal Antigen Screening as a Strategy to Prevent HIV-Associated Cryptococcal Meningitis in South Africa. PLOS ONE, 8 (7). e69288 -e69288 (10). ISSN 1932-6203 https://doi.org/10.1371/journal.pone.0069288
SGUL Authors: Harrison, Thomas Stephen Jarvis, Joseph Nicholas

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Abstract

Objectives Cryptococcal meningitis (CM)-related mortality may be prevented by screening patients for sub-clinical cryptococcal antigenaemia (CRAG) at antiretroviral-therapy (ART) initiation and pre-emptively treating those testing positive. Prior to programmatic implementation in South Africa we performed a cost-effectiveness analysis of alternative preventive strategies for CM. Design Cost-effectiveness analysis. Methods Using South African data we modelled the cost-effectiveness of four strategies for patients with CD4 cell-counts <100 cells/µl starting ART 1) no screening or prophylaxis (standard of care), 2) universal primary fluconazole prophylaxis, 3) CRAG screening with fluconazole treatment if antigen-positive, 4) CRAG screening with lumbar puncture if antigen-positive and either amphotericin-B for those with CNS disease or fluconazole for those without. Analysis was limited to the first year of ART. Results The least costly strategy was CRAG screening followed by high-dose fluconazole treatment of all CRAG-positive individuals. This strategy dominated the standard of care at CRAG prevalence ≥0.6%. Although CRAG screening followed by lumbar puncture in all antigen-positive individuals was the most effective strategy clinically, the incremental benefit of LPs and amphotericin therapy for those with CNS disease was small and additional costs were large (US$158 versus US$51per person year; incremental cost effectiveness ratio(ICER) US$889,267 per life year gained). Both CRAG screening strategies are less costly and more clinically effective than current practice. Primary prophylaxis is more effective than current practice, but relatively cost-ineffective (ICER US$20,495). Conclusions: CRAG screening would be a cost-effective strategy to prevent CM-related mortality among patients initiating ART in South Africa. These findings provide further justification for programmatic implementation of CRAG screening.

Item Type: Article
Additional Information: PubMed ID: 23894442. Copyright: © 2013 Jarvis et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Keywords: Science & Technology, Multidisciplinary Sciences, Science & Technology - Other Topics, IMMUNODEFICIENCY-VIRUS-INFECTION, SYSTEMIC FUNGAL-INFECTIONS, PLACEBO-CONTROLLED TRIAL, SUB-SAHARAN AFRICA, ANTIRETROVIRAL THERAPY, PRIMARY PROPHYLAXIS, OPPORTUNISTIC INFECTIONS, FLUCONAZOLE PROPHYLAXIS, DOUBLE-BLIND, ITRACONAZOLE PROPHYLAXIS
SGUL Research Institute / Research Centre: Academic Structure > Infection and Immunity Research Institute (INII)
Journal or Publication Title: PLOS ONE
ISSN: 1932-6203
Dates:
DateEvent
19 July 2013Published
PubMed ID: 23894442
Web of Science ID: 23894442
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URI: https://openaccess.sgul.ac.uk/id/eprint/102017
Publisher's version: https://doi.org/10.1371/journal.pone.0069288

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