1 / 14

Radha Rajasingham, David Meya, Melissa Rolfes, Kate Birkenkamp , David R Boulware

Cost-Benefit of Integrating Cryptococcal Antigen Screening and Preemptive Treatment into Routine HIV Care. Radha Rajasingham, David Meya, Melissa Rolfes, Kate Birkenkamp , David R Boulware Presented by: Radha Rajasingham, MD July 23, 2012. Background.

isra
Download Presentation

Radha Rajasingham, David Meya, Melissa Rolfes, Kate Birkenkamp , David R Boulware

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Cost-Benefit of Integrating Cryptococcal Antigen Screening and Preemptive Treatment into Routine HIV Care Radha Rajasingham, David Meya, Melissa Rolfes, Kate Birkenkamp, David R Boulware Presented by: Radha Rajasingham, MD July 23, 2012

  2. Background • Cryptococcal Meningitis causes ~20-25% of AIDS-related attributable mortality in sub-Saharan Africa • Cryptococcal Antigen (CrAg) can be detected >3 weeks before onset of symptoms • Asymptomatic CrAg+ persons have a high risk of subsequent CM and death, despite ART. • A new CrAg point of care lateral flow assay (LFA) is available with excellent sensitivity and specificity

  3. Methods • We assessed the cost-benefit of targeted CRAG screening for patients with CD4<100 using the LFA ($2.50/screen) coupled with preemptive fluconazole therapy for CRAG+ persons entering HIV care in sub-Saharan Africa • CRAG LFA Cost Components • CRAG LFA Assay $2.00 www.Immy.com • Lab Supplies $0.05 One pipette tip, one Eppendorf tube • Labor $0.25 • Overhead $0.20 • LFA can be shipped/stored at room temperature

  4. Performed CRAG screening at the Infectious Disease Institute in Kampala Uganda between 2004 and 2007 • CRAG latex agglutination was $16.75 per test • Among HIV+ with a CD4<100, 8.8% (26/295) had asymptomatic/subclinical cryptococcal antigenemia • 21 were treated with fluconazole (200-400mg x 2-4 weeks), 30-month survival was 71% • 5 were not treated with fluconazole, and all died within 2 months of starting ART Clinical Infectious Diseases 2010; 51:448-55.

  5. Cost-Effectiveness Analysis • Among CD4<100, the number needed to screen in order to detect one CRAG+ was 11.3 (95% CI: 7.9-17.1) • NNS = 1 / prevalence • NNS = 1 / 0.088 • The number needed to be screened and treated to prevent one death was 15.9 people • NNT life-saved = 1 / (prevalence * survival) • NNT life-saved = 1 / (0.088 * 0.71)

  6. Based on $16.75 CRAG, this translates to: • $190 (95% CI: $132-$286) to detect one asymptomatic person with cryptococcal antigenemia • $266 (95% CI: $185 to $402) to save one person’s life with preemptive fluconazole • Assuming an average increase in life expectancy of 18 years for a 30yo Ugandan initiating ART with a CD4<100,* this is $14.77 per DALY saved * Mills EJ, Bakanda C, Birungi J, et al. Life expectancy of persons receiving combination antiretroviral therapy in low-income countries: a cohort analysis from Uganda. Ann Intern Med 2011; 155: 209-216

  7. CRAG Lateral Flow Assay (LFA) Immunochromatographic LFA test FDA approved July 2011

  8. Using the same assumptions • Among HIV+ with CD4<100 cells/µL with CRAG+ prevalence of 8.8%: • To detect one CRAG+, the number need to screen was 11.3 (95% CI: 7.9-17.1) • To prevent one death, 15.9 people would need to be screened and treated

  9. Based on CRAG LFA cost of $2.50: • The cost of detecting one person with subclinical antigenemia with the LFA is $28.37 (95% CI: $20 to $43) • The cost of saving one life is $39.73 (95% CI: $28 to $60) • Assuming an average increase in life expectancy of 18 years for a 30yo Ugandan initiating ART with a CD4<100,* this is $2.21 per DALY saved * Mills EJ, Bakanda C, Birungi J, et al. Life expectancy of persons receiving combination antiretroviral therapy in low-income countries: a cohort analysis from Uganda. Ann Intern Med 2011; 155: 209-216

  10. Prevalence of asymptomatic antigenemia with corresponding cost per life saved based on LFA cost of $2.50 per test

  11. No CrAg Screening CrAg Latex Agglutination CrAg Lateral Flow Assay

  12. CRAG Screening is Cost Saving • Conversely, the cost of hospitalization and 14 days of amphotericin for treatment of cryptococcal meningitis is: • $425 per episode in Uganda • $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 Savingcompared to the cost of amphotericin and CM treatment

  13. Conclusions • Targeted CRAG screening and preemptive fluconazole therapy is cost-saving to health care systems and should be integrated into routine HIV care for persons with CD4<100. • Better understanding of the implementation science is needed to determine how best to scale up CRAG screening and define optimal treatment.

More Related