Improved 12-month survival when community support given with cryptococcal antigen screening in HIV
March 14 2015
Around 10 million people in Africa receive antiretroviral therapy (ART) for HIV infection, but mortality in the first few months and during the first year is higher than in Europeans. Tuberculosis and cryptococcal meningitis account for the majority of deaths in Africa in HIV patients.
A paper published in the Lancet online this week has highlighted that the provision of a short period of community support from lay workers alongside screening for cryptococcal antigen, substantially reduces mortality in patients with advanced HIV disease, who are commencing antiretroviral therapy. The mortality was 30% less in patients who had received this package which cost between $30 -70 per patient.
This open label randomised trial took place in Tanzania and Zambia with 1999 patients and the result was consistent in both countries. Patients with a CD4+ count of less than 200 cells per μL and over 18 years were eligible for recruitment. Four home visits (weekly)from a community worker were provided during the first 4 weeks of ART treatment to the community/antigen tested group.
Screening for cryptococcal antigen was done using a point-of-care serum rapid antigen test (IMMY, Norman, OK, USA). Participants who were serum antigen negative were started on ART immediately. Those who were serum antigen positive – in fact 4% of that group – were given either Amphotericin B treatment or fluconazole treatment depending on whether cryptococcal antigen was determined in CSF. ART was delayed by 2 weeks in patients who were serum cryptococcal antigen positive.
The shortage of qualified health care workers is a challenge in Africa, but this study indicates that some simple community support alongside screening for cryptococcal antigen could be an easily implemented strategy for reducing mortality in HIV patients with advanced disease.