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Cost-effectiveness of primary prophylaxis of AIDS associated cryptococcosis in Cambodia
Romain Micol1, Ayden Tajahmady, Olivier Lortholary
1Unité d'Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France. romain.micol@gmail.com
Insights
Cryptococcal infection prevention in Cambodian HIV patients with low CD4 counts is cost-effective. Serum antigen screening and fluconazole prophylaxis improve survival compared to no intervention, with screening being more cost-effective overall.
Area of Science:
- Infectious Diseases
- Public Health
- Health Economics
Background:
- Cryptococcal infection is a leading cause of mortality in Cambodian HIV-infected individuals with CD4+ counts ≤100 cells/µl.
- This study evaluates the cost-effectiveness of different cryptococcosis prevention strategies.
Purpose of the Study:
- To compare the cost-effectiveness of no intervention, serum cryptococcal antigen (CRAG) screening, and primary fluconazole prophylaxis for HIV patients with CD4+ counts ≤100 cells/µl in Cambodia.
Main Methods:
- A Markov decision tree model simulated a cohort of HIV-infected patients over one year.
- Strategies compared included no intervention, one-time CRAG screening with treatment, and systematic primary fluconazole prophylaxis.
- Data on natural history, costs (US$ 2009), and efficacy were sourced from Cambodia and international literature.
Main Results:
- One-year survival was 61% (no intervention), 70% (screening), and 72% (prophylaxis).
- Cost-effectiveness was US$180/life year gained (LYG) for screening vs. no intervention.
- Cost-effectiveness was US$511/LYG for prophylaxis vs. screening, and US$1538/LYG if CD4+ counts ≤50 cells/µl decreased by 75%.
Conclusions:
- Both serum CRAG screening and primary prophylaxis are cost-effective for preventing AIDS-associated cryptococcosis in HIV patients with CD4+ counts ≤100 cells/µl.
- Screening is more cost-effective but less effective than prophylaxis in the short term.
- Prophylaxis is recommended for CD4+ counts <50 cells/µl, while screening is preferred for CD4+ counts between 51-100 cells/µl.
Background:
Cryptococcal infection is a frequent cause of mortality in Cambodian HIV-infected patients with CD4+ count ≤100 cells/µl. This study assessed the cost-effectiveness of three strategies for cryptococcosis prevention in HIV-infected patients.
Methods:
A MARKOV DECISION TREE WAS USED TO COMPARE THE FOLLOWING STRATEGIES AT THE TIME OF HIV DIAGNOSIS: no intervention, one time systematic serum cryptococcal antigen (CRAG) screening and treatment of positive patients, and systematic primary prophylaxis with fluconazole. The trajectory of a hypothetical cohort of HIV-infected patients with CD4+ count ≤100 cells/µl initiating care was simulated over a 1-year period (cotrimoxazole initiation at enrollment; antiretroviral therapy within 3 months). Natural history and cost data (US$ 2009) were from Cambodia. Efficacy data were from international literature.
Results:
In a population in which 81% of patients had a CD4+ count ≤50 cells/ µl and 19% a CD4+ count between 51-100 cells/µl, the proportion alive 1 year after enrollment was 61% (cost $ 472) with no intervention, 70% (cost $ 483) with screening, and 72% (cost $ 492) with prophylaxis. After one year of follow-up, the cost-effectiveness of screening vs. no intervention was US$ 180/life year gained (LYG). The cost-effectiveness of prophylaxis vs. screening was $ 511/LYG. The cost-effectiveness of prophylaxis vs. screening was estimated at $1538/LYG if the proportion of patients with CD4+ count ≤50 cells/µl decreased by 75%.
Conclusion:
In a high endemic area of cryptococcosis and HIV infection, serum CRAG screening and prophylaxis are two cost effective strategies to prevent AIDS associated cryptococcosis in patients with CD4+ count ≤100 cells/µl, at a short-term horizon, screening being more cost-effective but less effective than prophylaxis. Systematic primary prophylaxis may be preferred in patients with CD4+ below 50 cells/µl while systematic serum CRAG screening for early targeted treatment may be preferred in patients with CD4+ between 51-100 cells/µl.
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