Clinical infectious diseases : an official publication of the Infectious Diseases Society of America · 2026
Clinical Impact and Cost-Effectiveness of Improving Access to Cryptococcal Meningitis Diagnostics and Treatment in Malawi.
СтатьяПоддержка NIH: внешняя программаПоддержка исследования: вне правительства СШАНазвание и аннотация: Перевод в очереди
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Feser Mary, Maphosa Thulani, Shroufi Amir, Rangaraj Ajay, Talbot Virginia R, Songane Mario, Qian Yiqi, Matiya Eddie, Lawrence David S, Arena Caroline, Srinivasan Anjali, Nyirenda-Dziwani Eltas, Ford Nathan, Nyirenda Rose, Phillips Andrew, Freedberg Kenneth A, Tiam Appolinaire, Jarvis Joseph N, Hyle Emily P
Аннотация
BACKGROUND: Cryptococcal meningitis (CM) causes 13%-20% of deaths among people with HIV (PWH) globally. We examined the cost-effectiveness of improving access to CM diagnostics and treatment among PWH initiating HIV care with a positive serum cryptococcal antigen (CrAg) test in Malawi.
METHODS: We used the CEPAC-I model to simulate (1) Current care (CM treatment if diagnosed with CM; otherwise preemptive fluconazole) and assessed 7 intervention strategies to expand care: (2) lumbar puncture (LP); (3) semi-quantitative serum CrAg (CrAgSQ) alone; or (4) CrAgSQ plus confirmatory LP for asymptomatic people with CrAg+; and (5) 98% access to liposomal amphotericin B/flucytosine/fluconazole (LAmB/5FC/Fluc) for diagnosed CM, as well as improving access to CM treatment with each diagnostic strategy (6, 7, 8). The simulated cohort has mean CD4 27/µL, age 37 years; 16% have symptomatic CM, 28% asymptomatic CM, and 56% asymptomatic cryptococcemia. Model outcomes include 1-year survival, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) assessed at 2 cost-effectiveness thresholds: US$150/QALY and US$600/QALY.
RESULTS: Current care results in 70% 1-year survival, 10.67 QALYs, and costs US$2290/person. 98% access to LAmB/5FC/Fluc increases survival (+2.2%) and QALYs (+0.33 undiscounted QALYs) at lifetime costs of US$2320/person (ICER, US$140/QALY). CrAgSQ plus confirmatory LP for asymptomatic CrAg+ and 98% access to LAmB/5FC/Fluc results in +6.0% 1-year survival, +0.97 QALYs, +US$190/person (ICER, US$380/QALY). Results are sensitive to test characteristics and uptake.
INTERPRETATION: Improving access to LAmB/5FC/Fluc and expanding diagnostics to improve detection of asymptomatic CM would improve clinical outcomes and be cost-effective in Malawi and similar settings.
METHODS: We used the CEPAC-I model to simulate (1) Current care (CM treatment if diagnosed with CM; otherwise preemptive fluconazole) and assessed 7 intervention strategies to expand care: (2) lumbar puncture (LP); (3) semi-quantitative serum CrAg (CrAgSQ) alone; or (4) CrAgSQ plus confirmatory LP for asymptomatic people with CrAg+; and (5) 98% access to liposomal amphotericin B/flucytosine/fluconazole (LAmB/5FC/Fluc) for diagnosed CM, as well as improving access to CM treatment with each diagnostic strategy (6, 7, 8). The simulated cohort has mean CD4 27/µL, age 37 years; 16% have symptomatic CM, 28% asymptomatic CM, and 56% asymptomatic cryptococcemia. Model outcomes include 1-year survival, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) assessed at 2 cost-effectiveness thresholds: US$150/QALY and US$600/QALY.
RESULTS: Current care results in 70% 1-year survival, 10.67 QALYs, and costs US$2290/person. 98% access to LAmB/5FC/Fluc increases survival (+2.2%) and QALYs (+0.33 undiscounted QALYs) at lifetime costs of US$2320/person (ICER, US$140/QALY). CrAgSQ plus confirmatory LP for asymptomatic CrAg+ and 98% access to LAmB/5FC/Fluc results in +6.0% 1-year survival, +0.97 QALYs, +US$190/person (ICER, US$380/QALY). Results are sensitive to test characteristics and uptake.
INTERPRETATION: Improving access to LAmB/5FC/Fluc and expanding diagnostics to improve detection of asymptomatic CM would improve clinical outcomes and be cost-effective in Malawi and similar settings.