Cost-effectiveness of primary prophylaxis of AIDS associated cryptococcosis in Cambodia

• Published in: PloS one 2010-11, Vol.5 (11), p.e13856-e13856
• Main Authors: Micol, Romain, Tajahmady, Ayden, Lortholary, Olivier, Balkan, Suna, Quillet, Catherine, Dousset, Jean-Philippe, Chanroeun, Hak, Madec, Yoann, Fontanet, Arnaud, Yazdanpanah, Yazdan
• Format: Article
• Language: English
• Subjects: Acquired immune deficiency syndrome; AIDS; AIDS-Related Opportunistic Infections - prevention & control; Anti-Retroviral Agents - therapeutic use; Antifungal Agents - economics; Antifungal Agents - therapeutic use; Antiretroviral agents; Antiretroviral drugs; Antiretroviral therapy; Cambodia; Candida; CD4 antigen; CD4 Lymphocyte Count; Cost analysis; Cost-Benefit Analysis; Cotrimoxazole; Cryptococcosis; Cryptococcosis - etiology; Cryptococcosis - microbiology; Cryptococcosis - prevention & control; Cryptococcus; Developing countries; Disease prevention; Drug therapy; Economic aspects; Economic development; Fluconazole; Fluconazole - economics; Fluconazole - therapeutic use; Follow-Up Studies; Fungal infections; Health aspects; Highly active antiretroviral therapy; HIV; HIV infections; HIV Infections - complications; HIV Infections - drug therapy; Human immunodeficiency virus; Humans; Infection; Infections; Infectious Diseases/Epidemiology and Control of Infectious Diseases; Infectious Diseases/Fungal Infections; Infectious Diseases/HIV Infection and AIDS; Infectious Diseases/Infectious Diseases of the Nervous System; Intervention; LDCs; Life Sciences; Macroeconomics; Markov Chains; Markov processes; Medical diagnosis; Medical research; Meningitis; Monte Carlo simulation; Mortality; Patients; Prevention; Prophylaxis; Public Health and Epidemiology/Health Policy; Public Health and Epidemiology/Health Services Research and Economics; Public Health and Epidemiology/Immunization; Public Health and Epidemiology/Preventive Medicine; Public Health and Epidemiology/Screening; Santé publique et épidémiologie; Screening; Surveillance; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination - economics; Trimethoprim, Sulfamethoxazole Drug Combination - therapeutic use; Tuberculosis
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0013856

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. 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. 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%. 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.