Cryptococcal Antigenemia in Human Immunodeficiency Virus Antiretroviral Therapy–Experienced Ugandans With Virologic Failure
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Date
2020
Authors
Mpoza, Edward
Radha, Rajasingham
Tugume, Lillian
Joshua, Rhein
Nabaggala, Maria Sarah
Ssewanyana, Isaac
Nyegenye, Wilson
Kushemererwa, Grace Esther
Mulema, Vivienne
Kalamya, Julius
Journal Title
Journal ISSN
Volume Title
Publisher
Clinical infectious diseases
Abstract
Detectable serum or plasma cryptococcal antigen (CrAg) precedes symptomatic cryptococcal meningitis. The World Health Organization recommends CrAg screening for human immunodeficiency virus–positive persons with CD4 count <100 cells/μL initiating antiretroviral therapy (ART). However, an increasing proportion of patients with cryptococcosis are now ART experienced. Whether CrAg screening is cost-effective in those with virologic failure is unknown.
Methods
We retrospectively performed nationwide plasma CrAg testing among ART-experienced Ugandan adults with virologic failure (≥1000 copies/mL) using leftover plasma after viral load testing during September 2017–January 2018. For those who were CrAg positive, we obtained ART history, meningitis occurrence, and 6-month survival via medical records review.
Results
Among 1186 subjects with virologic failure, 35 (3.0%) were CrAg positive with median ART duration of 41 months (interquartile range, 10–84 months). Among 25 subjects with 6-month outcomes, 16 (64%) survived, 7 (28%) died, and 2 (8%) were lost. One survivor had suffered cryptococcal meningitis 2 years prior. Two others developed cryptococcal meningitis and survived. Five survivors were known to have received fluconazole. Thus, meningitis-free survival at 6 months was 61% (14/23). Overall, 91% (32/35) of CrAg-positive persons had viral load ≥5000 copies/mL compared with 64% (735/1151) of CrAg-negative persons (odds ratio, 6.0 [95% confidence interval, 1.8–19.8]; P = .001). CrAg prevalence was 4.2% (32/768) among those with viral loads ≥5000 copies/mL and 0.7% (3/419) among those with viral loads <5000 copies/mL.
Conclusions
In addition to the CD4 threshold of <100 cells/μL, reflexive CrAg screening should be considered in persons failing ART in Uganda with viral loads ≥5000 copies/mL.
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Citation
Mpoza, E., Rajasingham, R., Tugume, L., Rhein, J., Nabaggala, M. S., Ssewanyana, I., ... & Meya, D. B. (2020). Cryptococcal antigenemia in human immunodeficiency virus antiretroviral therapy–experienced Ugandans with virologic failure. Clinical infectious diseases, 71(7), 1726-1731. DOI: 10.1093/cid/ciz1069