Fig 1.
Base case model of CrAg screening reflexively for CD4 counts <100 cells/μL.
Table 1.
Description of HIV-infected population screened in CD4 testing and reflexive lab screening model.
Fig 2.
Base case model of treatment of Asymptomatic CrAg positive persons.
Fig 3.
Left: Base case model of care of those identified with cryptococcal meningitis after not being screened, not returning to clinic, not receiving preemptive treatment, or failing preemptive treatment. Right: Base case model of care of those identified as symptomatic blood CrAg positive, with early cryptococcal meningitis.
Table 2.
Input costs for CrAg screening and treatment.
Table 3.
Hospital costs and survival with alternative drug regimens.
Fig 4.
CrAg screening within HIV test-and-treat model.
Fig 5.
Treatment of Asymptomatic CrAg positive persons within the HIV test & treat model.
Table 4.
Description of HIV-infected Population Screened in HIV test & treat model.
Table 5.
Sensitivity of results to level of CrAg screening and proportion of patients with meningitis treated.
Fig 6.
Cost of CrAg screening and preemptive treatment with differential levels of implementation.
With 100% CrAg screening and treatment, 1900 lives are saved (44%) and $860,000 dollars, compared to no screening. Even with a small increase in CrAg screening from 0 to 10%, there are cost savings and deaths averted.
Table 6.
Sensitivity of results to alternative meningitis treatment strategies.
Fig 7.
Cost savings of CrAg screening with different treatment regimens for those with cryptococcal meningitis.
Left: CrAg screening and preemptive treatment where cryptococcal meningitis is treated with fluconazole alone. Right: Cryptococcal meningitis is treated with amphotericin + flucytosine. For analyses where meningitis was treated with fluconazole alone (which is highly ineffective), CrAg screening is cost-effective, but not cost-saving, because the treatment for meningitis is inexpensive. However, full implementation of CrAg screening resulted in a 44% reduction in mortality, given the poor efficacy of fluconazole in the treatment of meningitis. Conversely, if meningitis is treated with amphotericin + flucytosine, CrAg screening is cost-saving because treatment for meningitis is expensive, and reduces mortality. Mortality reductions are less dramatic with meningitis regimens that are more effective. In all scenarios, CrAg screening reduced mortality and was cost-effective.
Fig 8.
Cost of CrAg screening and preemptive treatment with differential levels of implementation with an HIV test-and-treat model.
With 100% CrAg screening and treatment, 53% of deaths are averted at a cost of $662 per death averted.