infections: cryptococcal meningitis and Kaposi’s sarcoma ... ·
Cryptococcal Antigen Screening in Uganda
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Cryptococcal Antigen Screening in Uganda
David R Boulware MD MPHRadha Rajasingham MD
David B Meya MMed
Infectious Disease Institute Makerere University
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CryptococcusTBBacterialAseptic/Viral
Cape Town, South Africa Kampala, Uganda
CryptococcusTBBacterialAseptic/Viral
Jarvis J et al. AIDS 2009
Etiologies of Meningitis in Africa
Unpublished 2006-2011 data
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0% 5% 10% 15% 20% 25%
Masaka, Uganda, CD4<200
Thailand (Rural), HIV+ pneumonia
Benin City, Nigeria, CD4<200
Bangkok, Thailand, CD4<100
Cape Town, South Africa, CD4<100
Cambodia, CD4<100
Kampala, Uganda, CD4<100, HIV clinic
Mbarara, Uganda, HIV clinic pop.
Tororo, Uganda, CD4<100
Kumasi, Ghana, CD4 <100
Kinshasa, DRC, HIV clinic pop.
Kisumu, Kenya, CD4<100
Kampala, Uganda, CD4<100
hospitalized
Cryptococcal Antigen (CrAg) Prevalence
Rhein J. Neurobehavioiral HIV Med 2012
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Meya D. Clin Infect Dis 2010
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Long Term Survival in Kampala
Butler E. et al. Submitted
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CrAg Latex Agglutination
CrAg Lateral Flow Assay
No CrA
g Scre
ening
Cost Effectiveness
Rajasingham MOAB0102
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Masaka, Uganda, CD4<200
Thailand (Rural), HIV+ pneumonia
Benin City, Nigeria, CD4<200
Bangkok, Thailand, CD4<100
Cape Town, South Africa, CD4<100
Cambodia, CD4<100
Kampala, Uganda, CD4<100, HIV clinic
Mbarara, Uganda, HIV clinic pop.
Tororo, Uganda, CD4<100
Kumasi, Ghana, CD4 <100
Kinshasa, DRC, HIV clinic pop.
Kisumu, Kenya, CD4<100
Kampala, Uganda, CD4<100
hospitalized
Cost per Life Saved by CrAg LFA Screening vs. Prevalence
Rhein J. Neurobehavioiral HIV Med 2012$2.50 CrAg LFA total test cost
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• Conversely, the cost of hospitalization and 14 days of amphotericin for
treatment of cryptococcal meningitis is:– $425 per episode in Uganda [WEPE028]– $2883 per episode in South Africa
• Thus for the treatment costs of 1 cryptococcal meningitis episode, one could perform CRAG LFA screening on: – 170 persons in Uganda– 1153 persons in South Africa.
• Above a CRAG+ prevalence of 1%, pre-ART CRAG screening is COST SAVING compared to the cost of any Cryptococcal Meningitis treatment
CRAG Screening is Cost Saving
Rajasingham MOAB0102
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CrAg Screening concept is great, but will it work in the
real world?
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ORCAS Trial• Operational Research in CrAg Screening
• Multisite CrAg Screening Project in Uganda• Implementation Science• Stepped Wedge Design, RCT• Roll out over 2 years
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IDI
CrAg Roll Out
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Design Lab-reflex test +POC CD4Clinician-based
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ORCAS Endpoints
• Primary: 6-month Survival
• Secondary: – Cryptococcal meningitis free survival time– Uptake of screening & pre-emptive treatment– Cost Effectiveness– Concordance between LFA & latex, other body
fluids
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Multiple ORCAS Partners
• Infectious Disease Institute– David Meya, Radha Rajasingham, Yuka Manabe
• University of Minnesota– David Boulware, Melissa Rolfes, Josh Rhein
• CDC and CDC-Uganda– Jonathan Kaplan, Emmy Bangizi Muramuzi,
Anthony Mukasa Mubiru, Ben Park, et al.