Background: Cryptococcal antigen (CrAg) screening for antiretroviral therapy (ART)-naïve adults with advanced HIV/AIDS can reduce the incidence of cryptococcal meningitis (CM) and all-cause mortality. We modeled the cost-effectiveness of laboratory-based “reflex” CrAg screening for ART-naïve CrAg-positive patients with CD4<100 cells/µL (those currently targeted in guidelines) and ART-experienced CrAg-positive patients with CD4<100 cells/µL .Methods: A decision analytic model was developed to evaluate CrAg screening and treatment based on local CD4 count and CrAg prevalence data, and realistic assumptions regarding programmatic implementation of the CrAg screening intervention. We modeled the number of CrAg tests performed, the number of CrAg positives stratified by prior ART experience, the proportion of patients started on pre-emptive antifungal treatment, and the number of incident CM cases and CM-related deaths. Screening and treatment costs were evaluated, and cost per death or disability-adjusted life year (DALY) averted estimated.Results: We estimated that of 650,000 samples undergoing CD4 testing annually in Botswana, 16,364 would have a CD4<100 cells/µL and receive a CrAg test, with 70% of patients ART-experienced at the time of screening. Under base model assumptions, CrAg screening and pre-emptive treatment restricted to ART-naïve patients with a CD4<100 cells/µL prevented 20% (39/196) of CM-related deaths in patients undergoing CD4 testing at a cost of US$2 per DALY averted. Expansion of preemptive treatment to include ART-experienced patients with a CD4<100 cells/µL resulted in 55 additional deaths averted  and was cost-saving compared to no screening. Findings were robust across a range of model assumptions.Conclusions: Reflex laboratory-based CrAg screening for patients with CD4<100 cells/µL is a cost-effective strategy in Botswana, even in the context of a relatively low proportion of advanced HIV/AIDS in the overall HIV-infected population, the majority of whom are ART-experienced. HIV-associated CM predominantly occurs in the setting of advanced HIV disease, typically at a CD4 T-cell count <100 cells/µL2. In patients with advanced HIV initiating antiretroviral therapy (ART), detection of cryptococcal antigen (CrAg) in the blood is highly predictive of subsequent CM3, with clinical symptoms usually developing within a few weeks4. CrAg screening with pre-emptive fluconazole therapy in CrAg-positive ART-naïve adults (without symptoms/signs of CM) has been shown to reduce all-cause mortality and is recommended by the World Health Organization (WHO) in adults starting ART with a CD4 <100 cells/µL6.Cryptococcal meningitis (CM) is a leading cause of mortality in people living with HIV/AIDS (PLWH) worldwide, causing an estimated 15% of HIV deaths7, has a mature HIV program providing free ART to citizens since 2002. Despite ART scale-up, advanced HIV/AIDS and CM remain common with almost 400 confirmed cases diagnosed per year in 2013 and 20149. In 2016, national HIV guidelines first recommended CrAg screening in ART-naïve, CrAg-positive patients with a CD4 <100 cells/µL10. For CrAg-positive ART-naïve patients, fluconazole 1200 mg/day for 2 weeks, then 800 mg/day for 8 weeks with ART initiation, then 200 mg/day until CD4 recovers to >200 cells/µL for at least 6 months is recommended. Currently, “reflex” screening (screening of any sample sent for CD4 testing below the CD4 count threshold) is conducted at the Botswana-Harvard HIV Reference Laboratory (BHHRL), which performs most CD4 testing in the urban Gaborone region. The cost-effectiveness of CrAg screening has not been evaluated in Botswana.Botswana, a country of approximately 2.3 million with a 2017 adult HIV prevalence of 23%13, and therefore only focused on ART-naïve patients. However, in Botswana as well as elsewhere in sub-Saharan Africa, over half of CM cases now occur in ART-experienced patients16, and reflex screening where CD4 monitoring is conducted is now identifying an important number of ART-experienced and CrAg-positive patients. This population represents a mix of individuals: 1) those recently started on ART without baseline CD4 and CrAg screening results following adoption of the HIV “test-and-treat” strategy17; 2) those on ART but with treatment failure; and 3) those started on ART with subsequent ART default re-engaging in ART care. Current CrAg screening guidelines do not address management of this growing population, although there is a highly plausible benefit of treating these CrAg-positive patients.In addition, with reflex CrAg screening, a new question has arisen: how to manage ART-experienced, CrAg-positive patients. With a laboratory-based, reflex CrAg screening program, a CrAg test is performed following all CD4 results <100 cells/µL. Since the lab does not know who is treatment-naïve and who is not, both ART-naïve and -experienced patients are CrAg screened. Previous models assumed that all or most CrAg-screened patients are ART-naïve18, with local CD4 distribution8, CrAg prevalence19, treatment outcomes14, ART status, and costing data. Two related policies are evaluated. For Policy 1, based on current guidelines, we modeled reflex CrAg screening for any patient with a CD4 <100 cells/µL and then pre-emptive treatment only for the ART-naïve patients10. The model for Policy 1 is used to estimate national costs for screening and the cost-effectiveness of this screening policy compared to no screening based on the cost per death averted and the cost per disability-adjusted life year (DALY). For Policy 2, we extend the analysis of Policy 1 to also incorporate pre-emptive treatment for ART-experienced individuals identified as part of reflex screening. We evaluated these models under a range of assumptions. The primary aim of our study was to model the cost-effectiveness of CrAg screening and targeted pre-emptive fluconazole treatment in Botswana using different screening and treatment policies. A decision analytic model was developed based on prior models19. Both studies received ethical approvals from the Botswana Health Research and Development Committee (HRDC) [HPDME 13/18/1] and the University of Pennsylvania Institutional Review Board (#827814), along with this cost-effectiveness analysis. CrAg testing is performed using the highly accurate CrAg lateral flow assay (LFA) 20, assumed for the analysis to be 100% sensitive and specific. Approximately 65,000 CD4 tests are performed annually at the BHHRL in 35,000 unique patients. With an estimated population of 370,000 adults in Botswana living with HIV, most of whom know their HIV-status and have engaged with HIV-care services22, this covers nearly 10% of the adult HIV-positive population in Botswana. We therefore chose to start with a model of 650,000 CD4 tests performed annually on a population of 350,000 adults to provide an estimate of the annual cost and impact of CrAg screening implementation at a national level. Our models include two components: 1) A reflex CrAg screening module; and 2) a treatment module.Our models use CD4 count distribution and CrAg prevalence data from the BHHRL in Gaborone, including data from a completed CrAg screening prevalence study conducted 2015–2016 and a second cohort from January 2018 through January 2019Underlying data23.The screening model estimates the proportion of patients who receive CD4 testing with a CD4 count <100 cells/µL, the proportion with prior evidence of ART use, the proportion CrAg-positive, the proportion who are preemptive treatment-eligible, and the proportion of these patients who remain asymptomatic and are targeted for preemptive therapy or are diagnosed with CM on urgent clinic follow-up after a positive CrAg test. The model includes imperfect “real-world” implementation, so that a proportion of eligible patients may not receive CrAg screening or are screened but do not receive timely evaluation.19. Only 30% of patients have no prior viral load testing documented in the national electronic medical record (EMR), Integrated Patient Management System. As baseline viral load testing is not performed in Botswana, with initial viral load testing 3–6 months after starting ART10, any client with viral load testing prior to CrAg screening can be assumed to be ART-experienced. Further, of CrAg-positive samples approximately 25% are assumed to be from patients with prior treated cryptococcal disease, which results in a persistently positive test result. These patients are not targeted for pre-emptive therapy. The remaining 75% of CrAg-positive patients are potentially eligible for pre-emptive fluconazole.In19. A high CrAg titer (>1:160) is associated with a high risk of CM without pre-emptive treatment in ART-naïve patients26. From local data, 59% of CrAg-positive patients with a CD4 <100 cells/µL have a high CrAg titer. A lumbar puncture is offered to all CrAg-positive patients evaluated for pre-emptive therapy to rule out prevalent CM, as up to one-third of even relatively asymptomatic CrAg-positive patients have prevalent meningitis diagnosed when evaluated by lumbar puncture (LP) and cerebrospinal fluid (CSF) testing26. As LP refusal is common27, we estimate that only 25% of patients consent to an LP. A total of 85% of high-titer and 15% of low-titer patients who undergo LP are diagnosed with prevalent CM and hospitalized25. The remaining CrAg-positive patients (i.e. those who did not undergo LP or had negative CSF testing) are targeted for pre-emptive fluconazole.We used local CrAg titer data to estimate the risk of ART-naïve CrAg-positive patients progressing to CM28. Of screened CrAg-positive patients, an estimated 25% with CD4 <100 cells/µL do not return to clinic quickly for evaluation and initiation of pre-emptive fluconazole and/or LP evaluation; these patients are also at a high risk of progression to CM.A proportion of CrAg-positive patients who should receive CrAg screening are not tested (5%), e.g. due to laboratory error or CrAg assay stockout. Without CrAg testing and pre-emptive fluconazole, these patients are at an high risk of incident CM, with risk influenced by a patient’s CrAg titer and how quickly ART is initiatedUnderlying data23.The treatment module estimates outcomes for (a) patients who should receive CrAg screening but do not and progress to CM, (b) those who receive screening but progress to CM without urgent follow-up and pre-emptive therapy, (c) those diagnosed with CM at the initial urgent follow-up visit, and (d) those who start but “fail” pre-emptive treatment, developing CM. Flowcharts for the treatment module are shown in28; we estimate that 20% of high-titer patients and 5% of low-titer patients started on pre-emptive fluconazole will fail pre-emptive fluconazole and go on to develop CM.For ART-naïve CrAg-positive patients, outcomes of pre-emptive treatment are derived from local estimates and a published systematic review14. Ten-week mortality for patients with a CD4 <100 cells/µL hospitalized for cryptococcal meningitis and treated with amphotericin B-based induction therapy is estimated to be 50%, with 17% of survivors experiencing relapse. CrAg-positive patients who are diagnosed with early CM on urgent follow-up or hospitalized after failing pre-emptive fluconazole are assumed to have a lower 10-week mortality (25% instead of 50% for those missed and not started on pre-emptive treatment) based on regional data25, with early recognition of infection and timely initiation of antifungal treatment associated with better survival. In our models, we assume that a minority of patients (20%) with incident CM die at home without being diagnosed, with a lower proportion who start on pre-emptive fluconazole (10%) or are diagnosed with CM at their initial follow-up (0%).For patients who progress to CM, case-fatality rates are derived from local data28. We estimate a higher risk compared to ART-naïve patients starting ART because of a greater likelihood of worse adherence or default in this population with previous ART default. For patients who recently started on ART with good virological response who are awaiting CD4 recovery, we assume a 10% risk of progression to CM without preemptive therapy, about half the risk in CrAg-positive ART-naïve patients starting ART who do not receive preemptive therapy28. As the median time to CM diagnosis is approximately 5 weeks in CrAg-positive patients newly starting ART without preemptive therapy and incidence of CM falls rapidly following ART initiation4, this estimate accounts for the fact that these patients have already been on ART for several weeks or months without a diagnosis of CM and therefore are likely at a lower risk of progression.In Policy 2, in addition to ART-naïve patients we model preemptive treatment for ART-experienced CrAg-positive patients with a CD4 <100 cells/µL. From 2018–2019 cohort data, approximately 70% of patients with a CD4 <100 cells/µL had documented HIV viral load testing by the time of CrAg screening indicating a history of ART use. Some of these ART-experienced patients have experienced ART failure or default and are assumed to be at high risk for progression to CM, whereas others are recently started on ART with HIV viral suppression awaiting immune recovery and assumed to be at comparatively lower risk for progression to CM. For CrAg-positive patients with ART treatment failure, without preemptive fluconazole therapy we assume a 90% risk of progression to CM based on anticipated delays in ART regimen change and prolonged immunosuppression. For CrAg-positive patients who have defaulted ART and are now re-engaging in care, we assume a 50% risk of progression to CM without preemptive fluconazole therapy, or approximately twice as high as the published risk of CM progression in CrAg-positive ART-naïve patients who do not receive preemptive therapyFrom 2018–2019 local cohort data, 40% of ART-experienced patients with a CD4 <100 cells/µL had a suppressed HIV viral load within 3 months prior to the date of CrAg screening and are assumed to fit into this lower-risk category (10% for CrAg-positive patients without preemptive therapy). The remaining 60% without recent HIV viral load testing or a recent non-suppressed HIV viral load are assumed to be at higher risk for CM progression due to ART default (50% risk in CrAg-positive without preemptive therapy) or treatment failure (90% risk in CrAg-positive without preemptive therapy). About half of these patients (30%) had no viral load testing in the previous 6 months and are assumed to have defaulted, whereas the other half (30%) had viral load testing within 6 months but with their last viral load unsuppressed and are assumed to have experienced treatment failure. For ART-experienced patients, given lack of published outcomes data in this population we assume that there is a 75% reduction in the risk of progression to CM with pre-emptive therapy. In the base model, we also assume that the same proportion of ART-experienced clients who are seen at urgent follow-up are diagnosed with CM by lumbar puncture as with ART-naïve clients. Screening and treatment flow diagrams are shown inUnderlying data23). Costs in Botswana Pula were converted to United States dollars (US$) using mid-2018 exchange rates . For CrAg screening, the cost per CrAg test is estimated at 50 Pula (US$4.71); to the wholesale price (~US$2), we factor in additional mark-ups from local distributors, shipment, and laboratory personnel costs. Fluconazole is relatively expensive in Botswana (at ~US$0.50 per 200 mg tablet through CMS) compared to other countries in the region and we assumed procurement through CMS rather than a pharmaceutical company drug donation program. Average length of maintenance therapy is estimated at 6 months, assuming some incomplete adherence.The costs of CrAg screening implementation and CM treatment are estimated from a provider-perspective using 2018 local supply costs from Botswana Central Medical Stores (CMS) for most parameter estimates 14. We assume a standard 14-day course of amphotericin B with high-dose fluconazole, intravenous fluid and electrolyte supplementation, and routine laboratory monitoring. Patients who survive hospitalization receive 8 weeks of fluconazole consolidation and 6 months of maintenance fluconazole on average. Patients who die within 10 weeks of treatment have lower utilization of treatment, laboratory, and post-discharge care and fluconazole (seeUnderlying data23).We do not have reliable local hospital “hotel” costs in Botswana for the treatment of CM. Therefore, WHO-CHOICE estimates for cost per day of hospital admission in 2008 are used assuming most cases are managed at referral/teaching hospitals with 100% occupancy and 10,000 admissions per year, and inflation-adjusting for 2018 prices using International Monetary Fund estimates14, age-specific, gender-averaged life expectancy of 36 additional years from 2016 WHO Global Health Observatory data31, and with a 3% annual discount rate, we estimated 21.4 DALYs avoided per death avoided. We then re-evaluated models with both ART-naïve (the target population for CrAg screening) and ART-experienced CrAg-positive patients being offered pre-emptive treatment. We do not factor in additional costs or deaths from CM relapse as these are small and unlikely to have a significant public health or health system cost impact.We estimate total annual costs of CrAg screening and treatment  from the provider perspective for each policy. Comparing these to a counterfactual scenario with no screening, we estimate the number of cryptococcal meningitis cases averted from screening, number of deaths prevented, and the cost per death averted as the incremental cost effectiveness ratio. We also evaluated cost per DALY avoided. With an average age of death from CM of 36 years from local dataWe performed a series of sensitivity analyses to account for areas of uncertainty or possible changes in CD4 testing practices. As Policy 2 dominated no CrAg screening and Policy 1 (see Results), all sensitivity analyses were performed for Policy 2:Sensitivity analysis 1: This model assumes 50% (versus 75% in the base model) of CrAg-positive patients return quickly for urgent follow-up and initiating of pre-emptive therapy with other parameter estimates remaining the same.Sensitivity analysis 2: This model assumes a combined 25% risk of CM progression for CrAg-positive ART-experienced patients without pre-emptive therapy (versus 46% in the base model) and with no CrAg-positive ART-experienced patients diagnosed with CM by lumbar puncture at urgent follow-up. Other parameter estimates remain unchanged. This sub-analysis accounts for uncertainty in the benefit of preemptive therapy for CrAg-positive ART-experienced patients given the lack of published literature in this group.Sensitivity analysis 3: This model assumes 70% of clients are ART-naïve and 30% ART-experienced  with risk of progression to CM with and without pre-emptive therapy unchanged. The sub-analysis was conducted to account for potential changes in CD4 testing practices.2; however, a proportion of patients will be diagnosed and hospitalized with CM without recent CD4 testing. The proportion of patients who are ART-naïve is consistent with local and regional estimates that half or more CM cases now occur in ART-experienced individuals15. The overall total cost for CM treatment is estimated at $851,716,Without CrAg screening, our base model estimates 17,225 CD4 counts <100 cells/µL. In the base model without CrAg screening, 305 patients with a CD4 <100 cells/µL develop CM without screening, 41% (126/305) are ART-naïve, and 196 CM-related deaths occur, with an additional 22 relapse CM cases . The numIn our CD4 <100 cells/µL base model, 16,364 CrAg tests are performed at a cost of $77,073. Without screening, we estimate 196 CM-related deaths annually in this CD4 <100 cells/µL population. For ART-naïve only, with CrAg screening and treatment, we estimate 39 lives saved (a 20% reduction in CM-related deaths among those patients with CD4 testing), at a cost of $43 per death prevented or $2 per DALY averted .Underlying data23 for results of sensitivity analyses).We next considered treating both ART-naïve as well as ART-experienced patients recognized as CrAg-positive through reflex screening. No additional costs are accrued for screening ART-experienced patients. Under base model assumptions, an additional 55 lives were saved through treatment of ART-experienced patients . Treatme10. This strategy, coupled with adoption of HIV “test-and-treat”32, contributes to a growing proportion of ART-experienced CrAg-positive individuals recognized through laboratory-based reflex screening in Botswana. Existing screening guidelines and modeling studies have not considered the impact of this large population or benefits of pre-emptive treatment. As in other studies from sub-Saharan Africa18, we found CrAg screening in ART-naïve patients with a CD4 <100 cells/µL to avoid a DALY for a low cost . Targeting only CrAg-positive ART-naïve patients for pre-emptive therapy, however, had a modest public health impact, preventing only 20% of CM-related deaths under base model assumptions. Additionally, treating CrAg-positive ART-experienced patients resulted in additional deaths prevented, and was cost-saving or avoided a DALY for a very low cost across a range of assumptions.Using robust local clinical, outcomes, and costing data, we provide the first estimates of the cost-effectiveness and impact of CrAg screening implementation in Botswana. This analysis was intended to be pragmatic, reflecting current CD4 testing practices in real world settings in Botswana, a country where national guidelines currently recommend CD4 testing at baseline (pre-ART), at three months, at 12 months and yearly thereafter for stable clients17, our findings may be less relevant in countries that do not support CD4 assessment following ART initiation. Nevertheless, in settings where post-ART CD4 testing is available, CD4 monitoring and CrAg screening—particularly in individuals with treatment failure or a history of default—may provide an additional public health benefit as the HIV epidemic matures in sub-Saharan Africa with a majority of cryptococcal meningitis occurring in ART-experienced individuals. International guidelines should address the clinical management in this emerging population, and future outcomes research is needed to better inform the benefit of preemptive therapy.CD4 testing remains necessary for identifying individuals with advanced HIV disease (i.e. low CD4 count) and guiding CrAg screening and other preventive measures against common opportunistic infections. With decreased funding for CD4 testing and an increasing focus on HIV viral load rather than CD4 monitoring in patients on ART19. Secondly, as a pragmatic study using real-world data, we did not evaluate other screening strategies such as point-of-care CD4 and/or CrAg testing, and focused on CrAg screening in clinic settings without considering a potential benefit in hospitalized patients34. Thirdly, our analysis may fail to account for future changes in CD4 testing practices in Botswana, including a potential shift away from CD4 testing as in other settings17. Finally, we limited our analysis to CrAg screening in patients with a CD4 count <100 cells/µL, reflecting current national guidelines. With the WHO recently conditionally recommending CrAg screening in individuals with a CD4 count of 100–200 cells/µL6, further analysis is needed to model the impact of CrAg screening and preemptive therapy in this patient population with a lower CrAg prevalence24.Our study has a number of limitations. First, we had significant uncertainty for a number of parameter estimates, particularly the risk of progression to cryptococcal meningitis for CrAg-positive individuals previously started on ART and the proportion of clients identified as CrAg-positive who receive urgent follow-up care in real-world settings. To account for uncertainty, we performed a series of sensitivity analyses demonstrating that CrAg screening avoids DALYs for a low cost, even with lower risk of CM progression in ART-experienced individuals or relatively poor urgent clinical follow-up. We also had robust local estimates for most cost and clinical parameters, particularly CD4 distribution, CrAg prevalence, and CM treatment outcomes data to support our findingsIn summary, using local estimates and accounting for uncertainty through sensitivity analyses, we found strong support for CrAg screening in Botswana for patients with advanced HIV at a threshold of <100 cells/µL. In addition to preemptive therapy in ART-naïve individuals, our findings provide support for pre-emptive treatment of CrAg-positive ART-experienced patients at a CD4 <100 cells/µL recognized in laboratory-based reflex CrAg screening programs. Future outcomes data is needed for this growing population and guidelines should consider the evidence for pre-emptive treatment in this group.https://doi.org/10.17605/OSF.IO/URXAG23.Open Science Framework: Cost effectiveness of cryptococcal antigen screening in Botswana.This project contains the underlying data used for this modeling study, including a description of all estimates and their sources under tab “Screening Parameter Estimates”.Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).Data are available under the terms of the WHO recommends CrAg screening for all PWH with CD4 count <100. A few studies from resource-constrained settings have shown CrAg screening to be cost-effective and is associated with improved survival among patients with advanced HIV disease. In the present study, the cost-effectiveness analysis accounted for CrAg screening and pre-emptive azole therapy in both ART-naive and ART-experienced PWH in Botswana - reflecting a real-world situation in Sub-Saharan Africa.  The assumptions used in the modelling are backed-up by local data. However, the authors seemingly overestimated the LP refusal rate . In effect, the estimated number of CM cases was lower than expected.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Thank you for these comments. Our estimate for the proportion of patients who screen CrAg-positive and consent to lumbar puncture is based on local data in Botswana. In a recent CrAg-screening cohort in which CrAg-positive patients were evaluated in clinic by a study doctor and nurse and asked to consent to lumbar puncture evaluation for meningitis, less than 40% on enrolled patients consented to lumbar puncture. In real-world settings without a dedicated study team, we assumed that consent to lumbar puncture evaluation would be lower. et al. have investigated the cost-effectiveness of reflexed laboratory-based CrAg screening based on CD4 counts <100 cells/μl. The model used is based on the assumption that 75% of patients will return for their CD4 count within days, and that 90% of these patients receive care for CM. Realistically, indeed based on evidence and knowledge of loss-to-follow-up (LTFU) rates in South Africa, the percentage of patients who return for treatment and care  is lower than the 75% assumed for this study. Assuming that 90% of patients with identified CrAg-positivity are enrolled for follow-up and receive care, may also be optimistic.Tenfordeet al. could therefore be considered a near best-case scenario outcome. Politicians and/or policymakers will use/act on the outcomes of such cost-effectiveness studies to decide whether (or not) to implement a widescale programme of care. In a resource poor setting, with a high burden of advanced HIV disease, such as seen throughout Southern Africa, such consideration is crucial to ensure the best use of limited resources. A best-case scenario could lead to unrealistic expectations, at lower cost expectations, especially if baseline assumptions, including the number of people who return for care and/ or who receive treatment, are higher than actual numbers. The model presented by Tenforde This is not so much a criticism of this work but more a comment on the practical value of cost-effectiveness work. Although it is important to present a scenario that will encourage policymakers to adopt, in this instance, widescale reflexed CrAg screening, policymakers may appreciate being presented with less-favourable outcomes too, so that they could additionally consider outcomes in a worst-case scenario. This approach would enable an understanding of how the overall outcome could be affected if fewer patients return for care before making any decisions about undertaking widescale implementation. The authors could therefore consider including some additional modelling and cost-effectiveness outcomes about a worst-case scenario. In my opinion, a worst-case review doesn’t detract from the expectation that the programme will be implemented. Rather it acts to emphasise to policymakers that systems need to be fully effective and in place for the programme to succeed and be cost-effective. It is an opportunity to identify possible challenges  so that problems can be dealt with beforehand. Thereafter, the best-case scenario model can be realised and the best-case cost-effectiveness that is predicted will prevail.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. We appreciate these comments from Dr. Glencross. As the reviewer states, in real-world settings a lower proportion of cryptococcal antigen (CrAg)-positive patients may return for urgent evaluation following CrAg screening.The baseline model that we present assumes successful national implementation of CrAg screening and pre-emptive treatment. We performed an additional sensitivity analysis  assuming that only 50% rather than 75% of screened CrAg-positive patients return for an urgent follow-up evaluation. Under this assumption, the cost of CrAg screening of only ART-naïve patients per disability-adjusted life year (DALY) averted was USD 138, with screening for both ART-naïve and ART-experienced being cost-saving. We concluded that screening implementation was likely still cost-effective even under less optimistic assumptions.


Patients with HIV and opportunistic infections (OIs), such as tuberculosis and cryptococcosis, have been recognised to have immune reconstitution inflammatory syndrome (IRIS) following initiation of highly active antiretroviral therapy (HAART). The initiation of HAART boosts CD4 T cells, which result in exacerbations of OIs. We have identified deterioration of neural lesion in imaging after the initiation of HAART in a patient with HIV/cryptococcal infection, although patient's clinical conditions have not deteriorated. It is evident that IRIS is in subtlety. This has been possible because of prompt treatment with antifungal drugs for the cryptococcal infection, followed by early initiation of HAART. Patients with HIV and opportunistic infections, such as tuberculosis and cryptococcosis, have been recognised to have immune reconstitution inflammatory syndrome following initiation of highly active antiretroviral therapy (HAART). The neurological manifestations following HAART may be devastating. Cryptococcal meningitis-immune reconstitution inflammatory syndrome (IRIS) reportedly has an incidence rate of 13%-30% in patients with HIV coinfections . These fA 32-year-old HAART-naive HIV seropositive male weighing 48 kg presented with forgetfulness, irritability and incontinence of urine, along with fever and headache for the last two months. His CD4+ cell counts were 36/μl, and he was seronegative for hepatitis B and C. He did not experience seizure or took anti-epileptic medication. Clinical examination revealed neurocognitive impairment with a mini-mental status score of 14/30. There was no focal neurological deficit. A computed tomography (CT) of the brain Figure  showed aFluconazole (200 mg per day) was continued along with HAART. At the end of six months, CD4+ cell counts were up to 246/μl and a further CT image Figure  showed aThe hypodense lesion Figure  is the rCattelan et al.  have repIn a retrospective study between 2005 and 2014, the imaging pattern in patients receiving HAART is found to be different from neuroimages in patients without HAART. All the patients on HAART show leptomeningeal and parenchymal enhancement in cortical and subcortical region of brain under immune reconstitution, while those without HAART have pseudocysts and lacunar infarcts .About one-third cases of cryptococcal meningitis experience mild to devastating form of IRIS after the initiation of HAART. In our case, neuroimaging enhancement in the left frontal lobe of the brain without any clinical exacerbation following HAART has been observed. This subtle form of IRIS is the result of rapid treatment of cryptococcal infection with antifungal drugs and prompt initiation of HAART.


Background: With the availability of direct acting antiviral treatment for hepatitis C (HCV), HIV and HCV co-infected patients show comparable treatment responses to HCV-monoinfected patients. An 8-week course of sofosbuvir/ledipasvir (SOF/LDV) is highly effective for the treatment of HCV genotype 1 infection in treatment-naïve mono-infected patients with HCV viral loads <6 million IU/ml. There is limited data on the efficacy of this 8-week HCV treatment regimen in HIV-infected individuals with similar viral loads.Methods: The study was a retrospective review of HIV-infected adults coinfected with HCV genotype 1 for whom an 8-week course of SOF/LDV was prescribed by providers at two clinics in the Yale-New Haven Health system from November 1, 2014 until April 30, 2016. Treatment efficacy was assessed as the proportion of treatment initiators who achieved a sustained virologic response 12 weeks after completion of therapy (SVR 12).Results: Nineteen patients met study eligibility criteria and included 14 men (74%); and 12 African-Americans (63%). All patients were on antiretroviral therapy with fully suppressed HIV viral loads and were HCV treatment-naïve. All patients had pre-treatment HCV viral loads <6 million IU/mL. Eighteen patients (95%) completed HCV treatment. Overall, SVR 12 was 95%, with 1 treament failure occurring due to suboptimal adherence.Conclusion: Among our HIV-infected patient cohort with HCV genotype 1 infection, 95% of those treated with an 8 week course of SOF/LDV achieved SVR 12. This is comparable to the efficacy of the same treatment regimen in patients without HIV infection. This study lends proof of concept to the use of shorter course SOF/LDV treatment for HIV-HCV genotype 1 coinfected patients with viral loads <6 million IU/ml. Larger studies are indicated to validate our findings. Among certain risk groups, such as injection drug users with HIV infection, prevalence rates as high as 90% have been reported (https://www.cdc.gov/hepatitis/populations/hiv.htm). HIV infection alters the natural history of HCV disease, such that there are higher and faster rates of progression to liver cirrhosis with its resultant complications; this negative interaction may not be impacted by the receipt of effective antiretroviral therapy (ART)2.HIV and hepatitis C virus (HCV) share similar epidemiologic risk factors and routes of transmission, such that among HIV infected individuals, the prevalence of HCV infection is high and estimated at 25%  can be successfully treated with 8 weeks of SOF/LDV. However, the guidelines cite limited data as the reason to not recommend an 8-week SOF/LDV treatment course for HIV-infected patients.The United States Food and Drug Administration (FDA) approved sofosbuvir/ledipasvir (SOF/LDV) in 2014 for the treatment of chronic HCV genotype 1 infection. The ION-3 study of SOF/LDV that included treatment-naïve non-cirrhotic patients with HCV genotype 1, found that the sustained virologic response 12 weeks after end of therapy (SVR12) was comparable between the 8-week (with and without ribavirin) and 12-week treatment arms in a post hoc analysis for patients who had a pre-treatment HCV viral load (VL) <6 million IU/ml12. Therefore, shorter HCV treatment regimens are likely to be as effective in HIV-infected individuals as their non-infected counterparts. Our study describes treatment outcomes of a short (8 week) course of SOF/LDV in HIV/HCV co-infected patients.Contemporary HCV treatment trials with directly acting antiviral (DAA) agents have shown that HIV infection status no longer independently impacts treatment outcomesWe performed a retrospective review of all HIV and HCV co-infected patients, for whom an 8-week SOF/LDV treatment course was initiated from November 1, 2014 until April 30, 2016. The treatment decision for short course therapy was made by individual clinic providers at two clinics based at Yale Health system in New Haven, CT, USA: Nathan Smith Clinic and the Haelen Center.Eligibility criteria for the study included all adult (age >18 years) patients with confirmed HIV infection who had HCV genotype 1 infection. Only individuals for whom treatment with an 8-week course of SOF/LDV was intended, were included in the analysis.13 and fibrosis-4 (FIB-4) score14. Patient-reported adverse events and reasons for non-completion or discontinuation of treatment were based on documentation in electronic medical records. Data were recorded and analyzed using descriptive statistics in Microsoft Excel, v2013. Overall SVR 12 rate was defined as the proportion of individuals for whom an 8-week treatment course was initiated that had undetectable HCV viral loads 12 weeks after completion of therapy.Electronic medical records of eligible patients were reviewed. Data collected included demographics, HIV clinical data ), and laboratory data, including complete blood counts, electrolytes, and liver function tests and biopsy results. Plasma HCV viral loads and genotypes were determined at our lab using COBAS Ampliprep/COBAS Taqman HCV Test, v2.0 . Assessment of liver fibrosis stage at time of treatment initiation was determined by one or more of the following: liver biopsy and non-invasive liver fibrosis scores, such as AST to platelet ratio index (APRI)Study approval was obtained from the Yale University Human Investigations Committee (number 1506016104).A total of 19 patients met the study inclusion criteria. Median age was 53 years (IQR 42-73 years); 14 (74%) were males, and 12 (63%) were African-American. The median body mass index was 28.2 kg/m2. The majority (95%) had glomerular filtration rate >60 ml/min. The major risk factor for HIV was injection drug use (53%). Median CD4 T cell count was 678 cells/µL (IQR 458-1004 cells/µL). All patients were on ART, of which non-nucleoside reverse transcriptase inhibitors (43%) followed by integrase strand transfer inhibitor-based regimens (32%) were most common. Thirteen patients (68%) were on tenofovir/emtricitabine (FTC) and 5 (26%) were taking abacavir/lamivudine (3TC). Patients who were on HIV protease inhibitors were receiving tenofovir/FTC. All patients had fully suppressed HIV VLs .Twelve (63%) patients had HCV genotype 1a and 5 (26%) had genotype 1b; in 2 patients, genotype 1 subtype was not done. Median AST and ALT values were 39 (IQR 31-63) units/L and 45 (IQR 32-70) units/L, respectively. All patients had baseline HCV VLs of < 6 million IU/mL and were HCV DAA treatment-naïve. Based on concordant non-invasive scoring (APRI and FIB-4 score), we classified two patients as having cirrhosis, (patients 2 and 3 in database), but both were clinically compensated (Child-Pugh Class A). One patient (patient 15) had discordant APRI (above cut-off) and FIB-4 scores (below cut-off), so was not classified as having cirrhosis.Eighteen patients (95%) completed 8 weeks of therapy. One patient was non-adherent due to active substance abuse and only completed the first 4 weeks of treatment. Adverse events while on treatment were reported by 6 patients as follows: diarrhea (n=1), abdominal pain (n=1), nausea (n=1), poor appetite (n=1), diffuse joint pains (n=1), and pruritus without rash (n=1). One patient who experienced fatigue due to influenza temporarily discontinued treatment for 7 days, but resumed treatment afterwards. There were no cases of renal insufficiency, including patients who were on HIV protease inhibitors and tenofovir/FTC. Overall, SOF/LDV was well tolerated with no treatment discontinuations due to adverse effects.All eligible patients had at least one HCV VL assay performed either at week 4 or week 8 of treatment and at 12 weeks following completion of therapy. At week 4 of treatment, 11 of 12 patients for whom there was available data, had undetectable HCV VLs; one patient had viremia that was less than the lower limit of detection of the assay (< 15 IU/ ml). At week 8 of treatment, 11 of 12 patients, who had available HCV VLs, had undetectable HCV VLs. The patient who had detectable HCV VL at week 8 had completed only 4 weeks of therapy and was subsequently non-adherent due to active substance use. In total 18 of the 19 patients achieved SVR 12. Therefore, overall SVR 12 rate was 95% . The twoSpreadsheet data showing baseline demographic and clinical characteristics, as well as treatment outcomes, of HIV-HCV patients treated with 8-week course of sofosbuvir/ledipasvirClick here for additional data file.Copyright: © 2018 Ogbuagu O et al.2018Data associated with the article are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).15. The presence of HIV infection confers a risk for accelerated progression of liver disease, even when HIV is virally suppressed16. For these reasons, it is important to ensure treatment of HCV for all HIV-infected persons, regardless of disease stage. Multiple studies have shown that HIV co-infection is no longer a significant predictor of poor HCV treatment outcomes, such that cure rates among individuals infected with HIV are similar to those who are uninfected17.HIV and HCV infections are often referred to as syndemics as they share similar routes of transmission and impact populations that have similar demographic and socio-economic profiles18, and issues of adherence and potential development of resistance or toxicity. Kowdleyet al. showed in a post hoc analysis that an 8-week treatment regimen of SOF/LDV resulted in a high SVR 12 rate among non-cirrhotic HCV infected individuals with genotype 1 infection that was non-inferior to an 8-week regimen with ribavirin or a 12-week regimen without ribavirin10. Lower relapse rates were observed among patients receiving 8 weeks of SOF/LDV who had baseline HCV RNA levels <6 million IU/ml . However, this study did not include HIV-infected individuals.There is interest in shorter HCV treatment durations for a number of reasons: the prohibitive cost of newer DAAs9. Unlike the previous study, this study found that pre-treatment HCV VL >6 million IU/ml in a subset of patients with HIV infection did not affect treatment outcomes, including relapse rates.In a subsequent real-world multi-national retrospective study of 634 patients, an 8-week course of SOF/LDV resulted in an overall SVR 12 of 98.1% in non-cirrhotic treatment-naïve individuals regardless of HCV VLs. This study included 16 HIV-infected individuals, and for those with VL >6 million IU/ml, 100% achieved SVR 128. All patients in the trial were on antiretroviral therapy with a median CD4 count of 604 cells/mm3. However, the cohort consisted of predominantly Caucasian and male patients (89%). Our patient demographic was different with more women (26% versus 11%), and comprised a majority of African-American patients (63%).Our study, showing an SVR 12 of 95%, is similar to the rates observed in a German cohort of 28 HIV-HCV co-infected patients, who showed a 96% response rate to 8 week therapy using SOF/LDV (GECCO-01 study)19. For treatment-naïve patients with HCV genotype 1, SVR 12 was 96% in the 12-week arm and 76% in the 8-week arm. However, it was observed that patients with HCV VL <2 million IU/ml performed better than those with viral loads >2 million IU/ml (SVR 12 of 100% versus 62%) supporting excellent efficacy with lower viral loads19.It is important to highlight that not all DAA-based 8 week treatment courses for HIV-infected patients have yielded satisfactory results. The phase 3 ALLY-2 study, explored 8-week and 12-week SOF/daclatasvir treatment courses in HIV-infected individuals with HCV genotypes 1-420. It is remarkable that 26% of subjects were women and almost two-thirds were African-American; two groups that are often under-represented in HCV treatment studies, and this thereby increases the generalizability of the study results. The two individuals with cirrhosis also achieved excellent treatment results. In spite of the small number of patients in our study, the concordance of our findings with the European cohort in the GECCO-01 trial, as well as the multi-center study reported by Kowdleyet al, lends support to its validity.Our 95% SVR 12 rate in individuals placed on short course treatment may be attributable to certain factors: excellent adherence (supported by well controlled HIV infection) and selection of individuals with low HCV viral loads, factors that are associated with higher likelihood of cureA limitation of our study is that it was retrospective, therefore data captured was dependent on the quality of documentation by patient providers. Our patient demographic may not be representative of patients in settings different from ours. There may be a treatment selection bias, whereby patients who were more likely to adhere to therapy and had characteristics favorable to achieving an optimal response were initiated on therapy by their clinic providers. Due to the low number of patients with cirrhosis in our cohort, it is not advisable to extend the conclusions to this subgroup.In summary, our study provides support for the use of an 8-week course of SOF/LDV as an effective treatment option for HIV and genotype 1 HCV co-infected individuals with HCV viral loads <6 million IU/ml.The data referenced by this article are under copyright with the following copyright statement: Copyright: © 2018 Ogbuagu O et al.Data associated with the article are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).10.5256/f1000research.11397.d21852221Dataset 1: Spreadsheet data showing baseline demographic and clinical characteristics, as well as treatment outcomes, of HIV-HCV patients treated with 8-week course of sofosbuvir/ledipasvir. doi,This medical review was approved by Yale University Human Investigations Committee (number 1506016104); individual patient consent was not required in this retrospective chart review. Revision is fine.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. General: This is a small retrospective study that adds to the evidence that those with HCV (genotype 1)-HIV co-infection and low viral load can be treated successfully with 8 weeks of Sofosbuvir/Ledipasvir. Adherence matters as the one treatment failure did not complete treatment. The data from this cohort (two patients not described) are not strong enough to recommend this strategy for those with established cirrhosis. On-treatment monitoring of HCV PCR adds little to treatment. Specific comments: 1. The introduction is a bit dated. We should no longer need to justify treatment of those with HIV co-infection as a priority population. The simple fact of HCV infection means that these individuals should be offered treatment. 2. Introduction points out that HIV infection status no longer independently impacts treatment outcomes. The introduction should ALSO point out that those with HCV without HIV, NO cirrhosis and low viral load can be successfully treated with 8 weeks of SOF/LDV. 3. Two patients were thought to be cirrhotic but clinically compensated - how compensated? They should be described further and they should be pointed out in Table 3 - what were platelet counts, INR, albumin, Bilirubin. 4. The discussion is repetitive - should not repeat what was said in introduction 5. Study presents data of on-treatment HCV PCR monitoring. Do the authors think that this is required?I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. General:This is a small retrospective study that adds to the evidence that those with HCV (genotype 1)-HIV co-infection and low viral load can be treated successfully with 8 weeks of Sofosbuvir/Ledipasvir. Adherence matters as the one treatment failure did not complete treatment. The data from this cohort (two patients not described) are not strong enough to recommend this strategy for those with established cirrhosis. On-treatment monitoring of HCV PCR adds little to treatment.Response- Thanks for the comment. Regarding the concern about recommending short course treatment for cirrhotics, we acknowledge in the limitations section that… “Due to the low number of patients with cirrhosis in our cohort, it is not advisable to extend the conclusions to this subgroup.”Also, we agree that on-treatment monitoring of HCV viral loads adds little to treatment especially as there are no “stoppage” rules based on pre-set viral load decay parameters monitored over time. We captured HCV viral load assessments as checked by clinic providers which was based on the clinic HCV treatment protocol at the time the study was conducted.Specific comments:1. The introduction is a bit dated. We should no longer need to justify treatment of those with HIV co-infection as a priority population. The simple fact of HCV infection means that these individuals should be offered treatment.Response- we agree that there is no longer a need to justify treatment of HIV infected patients with HCV as they experience similar treatment outcomes. We have eliminated the sentence “owing to this the treatment of HCV infection is prioritized for persons infected with HIV” from the revised manuscript2. Introduction points out that HIV infection status no longer independently impacts treatment outcomes. The introduction should ALSO point out that those with HCV without HIV, NO cirrhosis and low viral load can be successfully treated with 8 weeks of SOF/LDV.rdsentence of paragraph 3 of the introduction as follows: “Response: We have modified the 3http://www.hcvguidelines.org/full-report/hcv-testing-and-linkage-care) can be successfully treated with 8 weeks of SOF/LDV.Based on this data, the American Association for the Study of Liver Diseases/Infectious Diseases Society of America guidelines recommend that  treatment-naïve, genotype 1 patients without cirrhosis, are non-black, HIV-negative and with a pre-treatment HCV VL <6 million IU/ml . We have corrected this on the re-submission.  Both patients had APRI and Fib-4 scores that were above cut-off values that are suggestive of liver cirrhosis. We used the term “compensated” to mean that they had no documented clinical features of decompensation including development of HCC, ascites, porto-systemic encephalopathy or varices. We did calculate Child Pugh scores  and both patients were class A. Both of these last points are mentioned in the results section.4. The discussion is repetitive - should not repeat what was said in introductionResponse: Thank you. We have modified the discussion to remove redundant / repetitive statements.5. Study presents data of on-treatment HCV PCR monitoring. Do the authors think that this is required?Response: as stated in our first response to general comments -we agree that on-treatment monitoring of HCV viral loads adds little to treatment especially as there are no “stoppage” rules based on pre-set viral load decay parameters monitored over time. We captured HCV viral load assessments as checked by clinic providers which was based on the clinic HCV treatment protocol at the time the study was conducted Ogbuago and coworkers provide a small study on 19 HIV-HCV coinfected individuals that were treated with an 8-weeks course of sofosbuvir and ledipasvir. Overall, the SVR rate is 95% with only one individual not responding who was in-adherent. The study, although small, adds knowledge to the existing literature.The authors should point out more clearly that they are dealing with a difficult-to-treat population here: A high percentage of AAs, high levels of IDU, and high BMI. This values the results even more.In the Introduction the authors should point out that DAAs have changed treatment paradigms in HCV, but that 12 weeks treatment duration still proved to be the threshold hard to beat. It only worked so far with this regimen presented here. It will however change with new compounds.In the discussion, the description of the ION-3 trial is slightly inaccurate: The non-inferiority of the 8-weeks regimen was an endpoint of the study. The 6 mil viral load threshold was a post-hoc-analysis. Minor comments:I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. It is correct that our cohort consisting of predominantly AAs, current or ex-IDUs, with high median BMI, and who are HIV co-infected are traditionally hard to treat populations so that it does make the treatment results all the more remarkable and in spite of the small sample size. This is now reflected in the discussion as follows:"The high SVR12 rate in our study is even more remarkable given that all patients were HIV infected and a significant proportion were African-American, had a high BMI and were active or current IDUs, all of which are characteristics of traditionally hard to treat populations. "We have modified the sentence in the Introduction referencing 8-week and 12-week treatment regimens to suggest as accurately pointed out that for currently approved DAA regimens, 12-week treatment duration remains the standard for most patients, while 8 week regimens may be used for "selected cases". This is now reflected in the introduction as follows:"While 12-week DAA-based treatment regimens remain the standard treatment course for most HCV infected patients, emerging data suggests that 8-week rather than 12-week regimens may be effective for treatment among selected patients "The paragraph has been rephrased to accurately reflect the primary results of the open label randomized ION-3 study as well as post hoc analysis as follows:et al, in a phase 3 open label randomized trial, showed that an 8-week treatment regimen of SOF/LDV resulted in a high SVR 12 rate among non-cirrhotic HCV infected individuals with genotype 1 infection that was non-inferior to an 8-week regimen with ribavirin or a 12-week regimen without ribavirin 10 . In a post hoc analysis, lower relapse rates were observed among patients receiving 8 weeks of SOF/LDV who had baseline HCV RNA levels <6 million IU/ml ." "Kowdley In response to Dr Ingiliz's comments:


Cryptococcus causes 15% of AIDS-related deaths and in South Africa, with its high HIV burden, is the dominant cause of adult meningitis. Cryptococcal meningitis (CM) mortality is high, partly because patients enter care with advanced HIV disease and because of failure of integrated care following CM diagnosis. We evaluated pathways to hospital care, missed opportunities for HIV testing and initiation of care.We performed a cross-sectional study at five public-sector urban hospitals. We enrolled adults admitted with a first or recurrent episode of cryptococcal meningitis. Study nurses conducted interviews, supplemented by a prospective review of medical charts and laboratory records.From May to October 2015, 102 participants were enrolled; median age was 40 years (interquartile range [IQR] 33.9–46.7) and 56 (55%) were male. In the six weeks prior to admission, 2/102 participants were asymptomatic, 72/100 participants sought care at a public-sector facility, 16/100 paid for private health care. The median time from seeking care to admission was 4 days . Of 94 HIV-seropositive participants, only 62 (66%) knew their status and 41/62 (66%) had ever taken antiretroviral treatment. Among 13 participants with a known previous CM episode, none were taking fluconazole maintenance therapy. In-hospital management was mostly amphotericin B; in-hospital mortality was high . Sixty-four participants were discharged, 92% (59/64) on maintenance fluconazole, 4% (3/64) not on fluconazole and 3% (2/64) unknown. Twelve weeks post-discharge, 31/64 (48%) participants were lost to follow up. By 12 weeks post discharge 7/33 (21%) had died. Interviewed patients were asked if they were still on fluconazole, 11% (2/18) were not.Among hospitalised participants with CM, there were many missed opportunities for HIV care and linkage to ART prior to admission. Universal reflex CrAg screening may prompt earlier diagnosis of cryptococcal meningitis but there is a wider problem of timely linkage to care for HIV-seropositive people. Cryptococcus causes 15% of AIDS-related deaths [d deaths . Most cad deaths . CM-relad deaths  to 60% id deaths . Continud deaths . A studyd deaths .Hospital-based care of patients with CM puts substantial pressure on a health system. CM is a frequent cause of hospitalisation in South Africa and Uganda , 11. RouSouth Africa’s public healthcare system is tiered. Primary healthcare clinics are run by nurses with infrequent to regular visits from consulting doctors. All such clinics have a designated referral hospital. During the scale-up of the national ART programme, the care of a large proportion of HIV-seropositive individuals was shifted to nurses trained to initiate and continue ART at these clinics . Nurses South Africa has implemented interventions for CM prevention, early diagnosis and improved management. Amphotericin B deoxycholate has been available for routine CM treatment since 2005, though prevention, monitoring and management of toxicities related to this antifungal agent should be improved further . A proviThe aim of this study was to evaluate pathways prior to hospital care, missed opportunities to link to care or access ART and post-discharge outcomes among patients hospitalised with cryptococcosis during an early phase of CrAg screening in South Africa.We performed this cross-sectional study nested within a laboratory-based surveillance programme (GERMS-SA) for cryptococcosis. The study was conducted at five public-sector urban hospitals in South Africa’s Gauteng province from May to October 2015, before national roll-out of reflex laboratory CrAg screening. Three hospitals were selected from districts where reflex CrAg screening occured. Two hospitals were located in a district where reflex screening had not yet been implemented. At the time of our study, patients were only eligible for ART with a CD4 count ≤500 cells/μl .Cryptococcus neoformans or Cryptococcus gattii from any specimen. We assumed an episode was recurrent if we found a record of a prior laboratory-confirmed episode or prior antifungal treatment for CM within 30 days. For this nested study, participants were eligible for enrolment if they were ≥18 years old, admitted to the study hospitals with a first or recurrent episode of laboratory-confirmed or presumed CM (e.g. symptoms of meningitis plus a positive blood CrAg test and on amphotericin B) and provided informed consent. Persons with CM who were identified after their admission through routine surveillance audits of the NHLS laboratory information system (LIS), referred to as “audit cases”, were not available for interview and were therefore excluded. For potential participants with a decreased level of consciousness, surveillance nurses visited the patient during their hospital stay to check for an improvement; if no improvement occurred, or if the potential participant died in hospital, their next of kin was approached and offered participation in the study. Written informed consent was obtained from the participant or the next of kin after an explanation by the study nurse. Interviews were conducted by surveillance nurses in the preferred language of the participant or next of kin. Information collected included demographic details, contacts made with the health system during the course of the illness, processes which resulted in the current hospital admission, barriers and facilitators to accessing health care, management of the episode of cryptococcosis in hospital and in-hospital outcomes. Interviews were supplemented by a prospective review of medical and laboratory records. Approximately 12 weeks after hospital discharge, participants or their next of kin were contacted telephonically to assess vital status.As part of the GERMS-SA surveillance programme, surveillance nurses visited the hospital microbiology laboratory daily to check for positive cryptococcal test results. They were not involved in the reflex CrAg screening programme. An episode of cryptococcosis was defined by a positive cerebrospinal fluid (CSF) India ink test, a positive CSF or blood CrAg test or culture of The case report forms were piloted at a large academic hospital and relevant changes were then made. Data were captured on the standardised case report form, checked for correctness and captured in MS Excel. This dataset was merged with the GERMS-SA surveillance database using participant identifiers so that routine surveillance information  and additional information from this study were available for each participant. Stata version 14  was used for a descriptive epidemiological analysis. We used the Wilcoxon rank sum test to compare medians and Fishers’ exact test to compare categorical variables.Study approval was obtained from the research ethics committees of the University of the Witwatersrand and the London School of Hygiene & Tropical Medicine.During the study period from May through to October 2015, 345 cases of cryptococcosis were detected through surveillance; 218 cases detected through audit were excluded (participants not interviewed through routine GERMS-SA surveillance and thus very limited information was available) . Of 127 All 127 participants had a diagnosis of CM . Of 102 enrolled, 89 were first episodes and 13 recurrent and of 25 not enrolled, 21 were first episodes and four recurrent. None of the recurrent cases had a CSF CrAg test as the only positive test. Among the 102 enrolled participants, information was captured by participant interview in 70% (n = 71) and the remainder by next of kin interview. Eighty-five (83%) participants were from hospitals where CrAg screening was not operational and 17 from sites with routine CrAg screening. Of the 102 participants, only one had a screening blood CrAg test ≥14 days before her CM diagnosis, which may have prompted earlier CM diagnosis and treatment.Of the 102 participants, 100 had symptoms in the six weeks prior to their admission. The majority  first sought healthcare for symptoms at a public-sector clinic or hospital where a minimal or no fee is levied. A large number of visits were made to various health care providers before participants were admitted but mostly at public clinics  .Of 38 participants who did not first attend a primary healthcare clinic in the public sector and who answered the question, “what reasons best describe why you did not visit a public for your symptoms?”: 17/38 (45%) went directly to hospital because they were so ill, 10/38 (26%) preferred to look for help elsewhere, 5/38 (13%) were unsure that they needed to get help and 6/38 (16%) provided no reason or other reasons . Of 57 who visited a public clinic, 43 (75%) visited only one clinic and 48 (84%) visited the clinic closest to them; the nine who attended a clinic further from home had the following reasons: they were treated better (n = 2), they wanted privacy (n = 2), the participant was turned away from closest clinic (n = 1), there was a shortage of treatment at the nearer clinic (n = 1) and the participant was referred from work (n = 1).Of 100 participants, 16 paid for healthcare  and 12 went to a pharmacy or supermarket to buy medicines . No partOf 102 participants, 94 were HIV-seropositive, two were HIV-seronegative and six had an unknown HIV status . On interview, 78/94 (83%) knew that they or their relative had been tested for HIV, 11 said they had never been tested  and for five, this information was unknown . Of the 78 who knew they were tested, 62 (79%) said that they or their relative was HIV-seropositive, six said they were HIV-seronegative and 10 did not know . There were 41 participants who tested at a public clinic, 36 knew whether a CD4 count had been done: seven said they had no CD4 count done and 29 (80%) said they had a CD4 count performed but only 17 (58%) returned for their result. Reasons provided for not returning for their CD4 count results (n = 10) included: three felt too ill to come back, two relocated, two did not trust the result, two did not know to return, one could not wait for the result.At the time of the hospital diagnosis of cryptococcosis, there were 59 participants with a CD4 count ranging from 1–234 cells/μl ; only three had a CD4 count >200 cells/μl; five of those participants knew their CD4 count six months prior to their diagnosis of cryptococcosis.Thirteen of eighty-seven reported a previous episode of CM  and 11 of these knew they had received treatment for meningitis . Nine of 11 participants reported receiving fluconazole on prior discharge (two never received) for a period ranging from one week to 30 weeks . All nine stopped their fluconazole for one of the following reasons: a healthcare worker stopped treatment for three, three did not know to continue after their initial course, three stopped on their own (two felt better and one felt ill on fluconazole). Of those 13 participants with a recurrent CM episode, information on ART was available for eight of them and five were on ART.We collected treatment information during the admission for CM for 81 patients, 75 (93%) of whom received both amphotericin B (AmB) and fluconazole, five (6%) received AmB only and one received fluconazole only (800 mg twice daily for 10 days). Of the 77 who were on fluconazole (with a known duration of treatment), treatment ranged from 1–45 days . Of 78 patients who received AmB with a known duration of treatment, this ranged from 1–27 days .From the information available, we determined in-hospital outcome for 92 participants: 64 (70%) recovered and 28 (30%) died in hospital. For 26 of 28 participants who died in hospital (with date of death recorded), median time to death was 9.5 days . The only participant with CrAg screening done before diagnosis was a 40-year-old woman who had a blood CrAg test on 26 June 2015, followed by transfer to an academic hospital on 4 July where she started fluconazole that day and AmB the following day. A lumbar puncture (with an opening pressure of 40 cm CSF) was performed on 7 July confirming CM. She received treatment until 14 July and was discharged on fluconazole; she died a month later.Sixty-four participants were discharged alive from hospital, 59 (92%) of whom were discharged on fluconazole, three (4%) were not, two (4%) were unknown. Of the 64 participants who were discharged alive, 31 (48%) were lost to follow up at 12 weeks. Thirty-three of 59 (56%) participants discharged on fluconazole had outcome data, among whom 7/33 (21%) had died. Only participants who were interviewed were asked whether they were still taking fluconazole. Sixty-nine per cent (18/26) were interviewed: 2/18 (11%) had stopped the fluconazole; reasons were not explored. . AssuminIn this study of care pathways and outcomes in CM, we have described the difficulties that very ill patients faced when navigating the complex South African healthcare system. Other SSA countries face similar challenges with a large burden of HIV/AIDS diverting scarce resources from competing health needs. Healthcare system strengthening in SSA is central to improve delivery of care for HIV/AIDS, co-morbidities and other priority conditions. Obstacles to adequate delivery of care must be pinpointed within a health care system before they can be overcome –22. The Prior to CM diagnosis, we identified numerous missed opportunities relating to HIV testing, including participants who did not know their HIV status, those who said they had never been tested and those who had been tested but thought they were HIV-seronegative. Reasons for delays in HIV testing have been explored in prior studies: social stigma, a perception of low HIV risk until they have physical symptoms, uncertainty about ART availability and side effects remain issues to be dealt with –26.Linkage to HIV care is a challenging component of the HIV care cascade. There were missed opportunities related to pre-CM ART initiation, including lack of CD4 result follow up, incomplete ART adherence counselling and ART interruption. National laboratory-based cryptococcal disease surveillance data (GERMS-SA programme) in South Africa shows that more than half of patients admitted with cryptococcosis are ART-experienced  –29. EarlHIV self-testing  is a reRetention in ART care has many challenges including navigation through the healthcare system, individual perceptions and medication-related issues. Not all clinics are open 24 hours, waiting times may be very long and patients are concerned about loss of confidentiality. Mental health and alcohol/ substance abuse have further been found to impact retention in ART care , 36. StrThe national South African CrAg reflex laboratory screening programme has increased detection of cryptococcosis. From October 2016 to September 2017, 276 125 patients with a CD4 count <100 cells/μl were screened nationally (95% coverage) and 15 757 (5.7%) were identified with cryptococcal antigenaemia. The effectiveness of the programme in terms of mortality reduction is being evaluated through the NICD’s CAST-NET project [In-hospital management of CM included amphotericin B for the vast majority of participants. Despite this, the in-hospital mortality was high 30%). This may be related to use of less-effective antifungal regimens in a resource-limited setting, complications associated with healthcare-associated infections, toxicity of antifungal medicines and inadequate management of raised intracranial pressure. A new WHO guideline for cryptococcal disease (March 2018) includes a one-week short course of amphotericin B deoxycholate and 5-flucytosine followed by one week of fluconazole [0%. This Following discharge from hospital, patients reported difficulties with continuing antifungal treatment and linking to ART at an appropriate time, particularly related to an inadequate healthcare worker explanation of the need for long-term antifungal treatment for CM. Adherence is a key challenge in long-term treatment and should be promoted by good counselling and a caring environment before beginning ART and antifungal therapy. Of our study participants who were discharged on fluconazole and available for the 12-week follow up, two had discontinued fluconazole, though reasons were not pursued. Continued counselling and education throughout treatment, pill counts done at every visit, assisting with practical reminders, helping to problem solve, understanding the challenges of long-term therapy, encouraging disclosure to a friend or family so there is support and regular support groups are all useful in adherence. Improving health systems to avoid treatment stock outs, to make care more accessible, possibly longer opening hours, reducing waiting times ease of collecting medication in the community rather than only the clinic, are also necessary , 39. SysInformation post discharge was scarce; however, among patients for whom there was data, most were alive at 12 weeks. This is a biased estimate since “loss to follow-up” of HIV positive patients usually includes many unreported deaths. Assuming all who were lost to follow up died, mortality would have been 72% at 12 weeks. A study done in 2009, in a Johannesburg urban hospital, showed poor post-discharge linkage to care for TB/HIV and late presentation at a primary clinic for follow up. Twenty three per cent (137/456) of patients failed to link to TB care, 30% (138/456) who were linked arrived late (>1 week). Thirty eight per cent (186/486) of patients with HIV-associated TB failed to link to HIV care, but 32% (96/300) who were linked sought care more than 30 days late .Strengths of this study include its uniqueness being nested within an ongoing, active surveillance system. We enrolled 80% of potentially eligible participants and data were collected by prospective interview. The use of next of kin interviews helped to increase representation of the sickest patients in the data set. Limitations include missing data because of next of kin interviews, patients not knowing enough about their health, incomplete medical records, and incomplete recollection of dates of when the patient was ill or when he/she was on previous treatment. The follow-up study did not reach all patients, only half who recovered were contacted.We have documented common problems in the pathway to care for patients with CM. We documented many missed opportunities for HIV testing, ART initiation and linkage to post-discharge HIV care. CrAg screening may improve CM case-finding and the availability of 5-flucytocine regimen may reduce CM mortality but the incidence of CM is only likely to decrease substantially when more people know their HIV status and start ART earlier.S1 Dataset(XLSX)Click here for additional data file.


Adherence to antiretroviral treatment is a key challenge for paediatric HIV care. Among children and adolescents living with HIV, lower levels of adherence have been reported compared to adults. Individual, caregiver-, health services-related and sociocultural factors were shown to impact on these outcomes. Study objectives were to assess adherence in a paediatric population in rural Tanzania comparing two measurement methods, and to investigate the association between virologic suppression and demographic, clinical, drug- and family-related factors.This cross-sectional study was conducted among children and adolescents enrolled in Bukumbi HIV Care and Treatment Clinic  in the north of Tanzania, where the HIV prevalence is 7.2%. Adherence was measured through viral load and pill count. Kappa statistics assessed the level of agreement between the methods; bivariate and multivariable analyses identified factors independently associated with virologic suppression.N = 72 participants  with a median age of eight years were enrolled. 62.5% and 65.3% of the individuals presented an optimal adherence according to viral load and pill count respectively, but among 40% viral load results diverged from the pill count method. In multivariable analysis, living outside Misungwi district and having CD4 counts above 500/μl were significantly associated with optimal adherence.Children and adolescents living with HIV in Mwanza show high rates of suboptimal adherence. The poor agreement between pill count and viral load results raises concerns about the interpretation of these measurements in clinical practice. Children and adolescents accounted for approximately 10% of the 36.9 million people living with HIV worldwide in 2017, and about 80% came from Sub-Saharan Africa [The introduction of effective antiretroviral (ART) treatment in the 1990’s drastically reduced AIDS-related mortality and morbidity. Adherence to ART became one of the most important determinants of long-term survival . In addiAdherence encounters special challenges in children and adolescents ,5; whileAdherence behaviour is a dynamic process influenced by multiple factors. They can be categorized as characteristics of the child/adolescent, the caregiver and the family, the health care providers, the society and culture and the medication ,7,8. TheTanzania is one of the most HIV affected countries worldwide, with a prevalence of five percent . The JoiThe objective of this study was to assess the level of ART adherence among children and adolescents in one peripheral HIV centre of care in Mwanza region, by comparing two measurement methods, viral load determination and pill count. In addition, the demographical, clinical and social factors associated with optimal adherence were investigated.This cross-sectional study used quantitative routine monitoring data collected in an out-patient clinic for HIV, in Bukumbi CTC (Care and Treatment Clinic).Bukumbi CTC is located in Misungwi district, 40 km from the city of Mwanza. Mwanza region includes seven districts, predominantly rural . MisungwAt the end of 2016, N = 1116 individuals were followed-up at Bukumbi CTC; 1093 of them were on ART. In the clinic, n = 84 patients were < 18 years old. The clinic offers voluntary counselling and testing and medical consultations, provides first and second line ART for HIV-infected adults and children, as well as treatment of opportunistic infections and tuberculosis and baseline and follow-up laboratory investigations. Bukumbi CTC is partially financially supported by International Missionary Association, an Italian non-governmental organization.Study participants were all children and adolescents below 18 years and six months among the patients on ART, who were regularly followed-up at Bukumbi CTC for at least six months, and for whom of at least one VL determination was available for the period August 2016 to December 2017.Patients were clinically managed according to Tanzanian National Guidelines : accordith version available for all Tanzanian CTCs). Information regarding health workers’ assessment through pill count were collected from patients’ files, based on the follow-up visits from May 2017 and August 2017.Demographical and clinical data were obtained through an electronic software , child’s clinical characteristics , child’s drug regimen characteristics , caregiver/family’s characteristics , and adherence measured by pill count. Nutritional status was assessed as follow: among subjects below five years moderate malnutrition was defined when weight-for-height z score was between– 1 and– 2 z score, severe malnutrition was defined below– 3 z-score; from 5 years and above, weight-for-height per age and sex (BMI-for-age and sex) was adopted. Therefore moderate malnutrition was defined between the third and the fifth percentile, while severe malnutrition was below the third percentile.Performing the logistic regression, variables with a p-value ≤ 0.1 in the bivariate analysis were entered into the multivariable analysis. A backward stepwise regression analysis was applied, comparing the models through likelihood ratio test. The final model included all the variables with a p-value < 0.05, besides sex and age, considered as a priori possible confounders.The study was approved by the Institutional Review Board of the Institute of Tropical Medicine of Antwerp (on 30/03/2018). The principal researcher, a medical doctor previously employed in this setting, entirely took care of data extraction from the electronical database and from the patients’ files, respecting data confidentiality and patients’ anonymity. All data were managed anonymously, removing all personal identifiers, and analysed at aggregated level. All data were stored in password-protected files which only the researcher had access to. The Institutional Review Board of the Institute of Tropical Medicine of Antwerp waived the requirement for direct patient’s and parental consent because monitoring data were used.As shown in The characteristics of the study participants are described in Roughly two thirds of the enrolled subjects, i.e. 62.5% (47/72) had at least one HIV positive caregiver and 18.1% (13/72) of them had HIV positive siblings. About a half of the caregivers were biological mothers ; a third of the individuals,  were double orphans. More than half of the population, i.e. 59.7% (43/72) had at least one literate caregiver.Among the 72 analysed children and adolescents, 62.5% (45/72) achieved optimal adherence according to VL measurements, and 65.3% (47/72) according to pill count measurement.The level of agreement between the two tests was very poor . Based on bivariate analysis, among child’s demographical characteristics, living outside Misungwi district was the only variable significantly associated with viral suppression . Children younger than five years and male subjects were more likely to have viral suppression compared to their counterparts, but this was statistically not significant.Focusing on clinical features, having CD4 > 500/μl was significantly associated with viral suppression . Having optimal adherence measured with VL was positively associated with having WHO stage of III or IV, but it was statistically not significant.Among medication-related characteristics, longer time on ART and higher number of previous ART regimens were negatively associated with viral suppression .Among the factors related to the child’s family, having HIV positive siblings, having a caregiver other than the biological mother or being a double orphan were associated with viral replication, but these associations were statistically not significant. Children with HIV positive caregivers were more likely to be virally suppressed compared to those with HIV-negative caregivers, but again this was statistically not significant.Finally, the individuals who took 95% or more of the medication according to the pill count, where more likely to have achieved viral suppression, but this association was statistically not significant.In multivariable analysis, only living outside Misungwi district and having CD4 counts above 500/μl remained significantly associated with viral suppression .This is the first study addressing adherence in the specific context of Mwanza region, which has one of the highest HIV prevalence rates in Tanzania  and lackThis study delineates low percentages of optimal adherence to antiretroviral treatment among children and adolescents living with HIV in the rural setting of Mwanza region: in Bukumbi CTC more than one third of the analysed population were not adherent to ART and the assessment routinely performed by health care workers based on pill count only partially reflected the results of viral load monitoring.Two main factors were identified as being associated with suppressed vital load levels: children with a CD4 count above 500/μl and those coming from other districts than Misungwi were significantly more adherent compared to their counterparts.While the available literature shows great variation in estimated levels of adherence among children and adolescents , the proMost of the African studies which adopted pill count assessment found proportions of children and adolescents with optimal adherence to range between 35%  and 98.4Although the results of the two methods adopted to measure adherence in Bukumbi might appear similar at first sight, the Cohen’s Kappa coefficient of 16% showed a very limited agreement. This reflects the lack of a standardized and accurate method to assess adherence. Additionally, the coefficient’s 95% confidence interval, although very broad (from -7.2 to 38.84) still fitted the definition of weak agreement < 40% ). Despit% . DespiChildren with CD4 counts higher than 500/μl showed significant better adherence, measured by viral load determination, than those with lower CD4 counts in the multivariable analysis. This is in line with other studies, which reported an association between CD4 count and virologic suppression –19,41. OChildren living outside of the district of Bukumbi CTC were significantly more likely to be virally suppressed than their counterparts in the multivariable analysis. This is a surprising finding, since it contrasts with similar previous studies, which found shorter distances to the clinic to be associated with better adherence ,45. We mConcerning the relationship between age and adherence there is wide consensus in describing adolescence as the most challenging period for sustaining optimal adherence ,5,14,46.Among the young population of Bukumbi CTC, being on ART for longer time and a higher number of previous ART regimens were found to be associated with virologic failure in the bivariate analysis, but this was not confirmed in the multivariable analysis. These findings are consistent with the results reported by Vreeman et al. (2008) . HoweverHaving HIV positive caregivers has been described as a facilitator for optimal adherence . In our Several study limitations should be acknowledged. First of all, the small sample size of the enrolled paediatric population of Bukumbi CTC undermined the power of the analysis. Since our study was based on monitoring data, information regarding the factors associated with virologic suppression was limited to registered patients’ routine characteristics. The cross-sectional study design did not allow to draw any causal associations between investigated factors and adherence, nor to measure the evolution of adherence over time. An additional important limitation concerns the measurement of adherence. As described in literature, there is no gold standard to proper assess adherence to ART  and all In conclusion, this work provides a limited but accurate picture of an alarming scenario concerning virologic suppression among HIV positive children and adolescents in Mwanza region, Tanzania. From a public health perspective, it draws the attention to the need of setting up and promoting new preventive strategies and interventions addressed to children and adolescents and their caregivers, aiming at improving ART efficacy among these groups. Ultimately, this could contribute to reducing the transmission among the entire population.An accurate assessment of adherence is a complex task to be chosen and evaluated carefully. The most widely adopted methods, such as self/caregiver reported or pill count, are often not consistent with the viral load determination measurement. The existing methods should be better validated, and the agreement between viral suppression and other methods, such drug concentration in biologic samples or electronic drug monitoring, considering patient autonomy while being conducive to reach fundamental goals of high ART adherence . Such meFinally, factors associated with optimal or suboptimal adherence need to be investigated taking into account the context and the multiple levels at which they interact. Furthermore, a combination of quantitative and qualitative data, and their triangulation, could help to better explain the observed outcomes.S1 DatasetID: identification numberTB: y = positive history of active tuberculosis, n = negative history of tuberculosis activeDiagnHIV: date of HIV diagnosisDistrict: 1 = Misungwi, 2 = othersARVregimen:    1 = lamivudine+zidovudine+nevirapine, 2 = lamivudine+zidovudine+efavirenz,    3 = abacavir+lamivudine+efavirenz, 4 = abacavir+lamivudine+lopinavir/ritonavir (paediatric),    5 = abacavir+lamivudine+lopinavir/ritonavir (adult),    6 = tenofovir+emtricitabine+atazanavir/ritonavir,    7 = abacavir+lamivudine+atazanavir/ritonavirNregimen: number of previous regimensARVStart: date which ARV was startedARVtablet: number of ARV tablet/dayCTX: y = cotrimoxazole prophylaxis present, n = cotrimoxazole prophylaxis not presentVitamine: y = vitamine supplementation present, n = vitamine supplementation not presentIPT: y = isoniazid preventive treatment present, n = isoniazid preventive treatment not presentNutrition: 1 = normal, 2 = moderate malnourished, 3 = severe malnourishedInfection: number of infections that required antibiotics during the previous yearVLcat and VLRcat: 0 = < 20 copies/ml or not detectable VL, 1 = 20–1000 copies/ml VL,    2 = ≥1000 copies/ml VL, 3 = not availableAdherence and AdherenceR: By pill count 1 = good (>95%), 2 = fair (85–95%), 3 = poor (<85%)RelativeHIV: y = having at least one HIV caregiver, n = no HIV caregiverRelation: With the caregiver 1 = Mother, 2 = Father, 3 = Relative, 4 = OtherLiteracy: y = literate caregiver, n = illiterate caregiverSiblings: y = having at least one sibling, n = no siblingHIVSiblings: y = having at least one HIV sibling, n = no HIV sibling.(XLS)Click here for additional data file.