Cryptococcal Meningitis
Conditions
Keywords
HIV, Cryptococcus, Lateral Flow Assay, sub-Saharan Africa, Screening, treatment, cryptococcal meningitis
Brief summary
The study will determine if the initiation of a 'screen and treat' program for cryptococcal disease among HIV positive individuals decreases morbidity and mortality among individuals with CD4 count \< 100 cells/mm3. The study will screen individuals who are asymptomatic for CM and are either ART naïve or ART experienced with CD4 count \< 100 cells/mm3. The introduction of an cheap, easy to use point of care diagnostic test the lateral flow assay will facilitate rapid diagnosis of cryptococcal disease in resource limited settings. The investigators will determine the efficacy of the lateral flow assay in identifying latent and asymptomatic cryptococcal disease. The investigators will determine the efficacy of the test in detecting disease in readily available body fluids such as urine and whole blood obtained via finger-stick method. The investigators will also determine the cost effectiveness of a screen and treat approach for cryptococcal disease in Zimbabwe. The investigators also wish to understand why some individuals with low CD4 counts reactivate cryptococcal disease and screen positive for cryptococcal antigen (CrAg) while others with similar levels of immunocompromised do not.
Interventions
OTHERPre-emptive screening and treatment for cryptococcal disease
Preemptive screening for cryptococcal disease among individuals with CD4 counts below 100 cells/mm3 with anti fungal therapy for those what are Cryptococcus antigen positive. These participants will be followed longitudinally for 12 months to determine clinical outcome, with their outcome compared with similar patients who are cryptococcal antigen negative, who will also be followed longitudinally for 12 months.
Sponsors
Centers for Disease Control and Prevention
University of Zimbabwe
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Documented HIV positive test by standard national algorithm * CD4 count ≤100 cells/mm3 * Age \> 18 years * Residence within 50 km of Harare * Able to provide written informed consent
Exclusion criteria
* Presence of clinical symptoms suggestive of meningitis. * Recent history of CM within 2 weeks of enrollment, i.e., participants within the induction phase of therapy. * Individuals with severe hepatic injury, jaundice, alanine transferase (ALT) \>5x upper limit of normal * Individuals with renal failure, defined by an estimated Glomerular filtration rate (eGFR) ≤30 mL/min (using MDRD (Modification of Diet in Renal Disease) equation) * Currently known to be pregnant * A negative urine pregnancy test is required for study entry for women with childbearing potential. * The use of contraception will be recommended to women with childbearing potential while on high dose fluconazole therapy. Referral to family planning services will be given as necessary. * Previous allergy or other reaction to amphotericin B and/or fluconazole * Currently enrolled in another clinical trial/study
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| 12- month survival in CrAg-positive persons vs. CrAg-negative persons screened | 12 months |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Sensitivity, specificity, positive and negative predictive values of point-of-care urine CrAg LFAs | 24 months | — |
| Sensitivity, specificity, positive and negative predictive values of point-of-care whole blood CrAg LFAs | 24 months | — |
| Proportion of individuals with CD4≤100 cells/mm3 and a positive CrAg assay who have disseminated cryptococcal infection with either blood infection or CSF involvement | 24 months | — |
| 12-month survival among individuals with CD4≤100 cells/mm3 prior to implementation of CrAg screening program using historical controls | 24 months | Retrospective analysis |
| Cost of implementation of CrAg screening among individuals with CD4≤100 cells/mm3 | 24 months | — |
| Seroprevalence of asymptomatic cryptococcal antigenemia among individuals with CD4≤100 cells/mm3 in an urban population in Zimbabwe | 24 months | — |
| Incidence of cryptococcal and non-cryptococcal IRIS | 24 months | — |
| Barriers to uptake of diagnostic LP by individuals with asymptomatic cryptococcal antigenemia. | 24 months | Questionnaire will be administered to participants who are serum cryptococcal antigen positive who decline to undergo LP. |
| Inflammatory cytokines and functional impairments in antigen specific T cells that are associated with the development of cryptococcal antigenemia and meningitis. | 24 months | Analysis will be done by ELISA and Luminex assays, cell culture and flow cytometry techniques, data collected will be entered into a database and analyzed by patient characteristics. |
| Impact of ART mediated immune reconstitution on the inflammatory cytokine profile and the cryptococcal antigen specific CD4+ T cell response in those with serum and CSF cryptococcal antigenemia compared with those without. | 24 months | Analysis will be done by ELISA and Luminex assays, cell culture and flow cytometry techniques, data collected will be entered into a database and analyzed by patient characteristics. Data will be longitudinal including baseline characteristics and subsequent follow-up data at 6 months and 12 months. |
| Cryptococcus-associated mortality among individuals with CD4≤100 cells/mm3, | 24 months | — |
Countries
Zimbabwe
Outcome results
None listed