Prevalence of Advanced HIV Disease, Cryptococcal Antigenemia, and Suboptimal Clinical Outcomes Among Those Enrolled in Care in Vietnam

Abstract

Background: People living with advanced HIV disease are at high risk of morbidity and mortality. We assessed the prevalence of cryptococcal antigenemia (CrAg) and clinical outcomes among patients newly presenting with CD4 ≤100 cells/μL in Vietnam. Setting: Twenty-two public HIV clinics in Vietnam. Methods: During August 2015–March 2017, antiretroviral therapy (ART)-naïve adults presenting for care with CD4 ≤100 cells/μL were screened for CrAg. Those who consented to study enrollment were followed up for up to 12 months and assessed for clinical outcomes. Results: Of 3504 patients with CD4 results, 1354 (38.6%) had CD4 ≤100 cells/μL, of whom 1177 (86.9%) enrolled in the study. The median age was 35 years (interquartile range 30–40); 872 (74.1%) of them were men, and 892 (75.8%) had CD4 <50 cells/μL. Thirty-six patients (3.1%) were CrAg-positive. Overall, 1151 (97.8%) including all who were CrAg-positive initiated ART. Of 881 patients (76.5%) followed up for ≥12 months, 623 (70.7%) were still alive and on ART at 12 months, 54 (6.1%) had transferred to nonstudy clinics, 86 (9.8%) were lost to follow-up, and 104 (11.8%) had died. Among all 1177 study participants, 143 (12.1%) died, most of them (123, 86.0%) before or within 6 months of enrollment. Twenty-seven patients (18.9%) died of pulmonary tuberculosis, 23 (16.1%) died of extrapulmonary tuberculosis, 8 (5.6%) died of Talaromyces marneffei infection, and 6 (4.2%) died of opioid overdose. Eight deaths (5.8%) occurred among the 36 CrAg-positive individuals. Conclusions: Late presentation for HIV care was common. The high mortality after entry in care calls for strengthening of the management of advanced HIV disease.

Updated estimation of the burden of fungal disease in Vietnam

“…Cryptococcal meningitis infection occurred in both HIV and non‐HIV groups at a ratio of 4:1 28 . In the HIV population, 3.1% were found to be positive for cryptococcal antigenaemia (CrAg), and 70% of CrAg‐positive cases would develop cryptococcal diseases 26,29 . Based on these reported figures, we estimated approximately 451 cases of CM (0.5/100,000 annually), with 361 in the HIV group and 90 in the non‐HIV group.…”

“…According to two different reports from Vietnam, 38.6% of newly diagnosed HIV patients would have a CD4 count ≤100 cells/μl and 7.2% of patients on ART would develop drug resistance, we expected about 5387 new AIDS cases and 11,230 cases with virologic failure in 2020. 26 , 27 Therefore, the total population at risk used to estimate the burdens of CM, PCP and histoplasmosis was 16,617 cases.…”

Host populations, challenges, and commercialization of cryptococcal vaccines

“…Instead, these governments should consider the savings that the vaccination strategy will bring on the health care system by preventing the costs associated with treatment or/and hospitalization of the subjects affected by that disease. For example, even if we consider a mere 3% prevalence of cryptococcosis among ADH patients (approximately 195,000 subjects-a very conservative figure) [36,41,42] and a treatment cost of approximately $2,000 per patient for only 2 weeks of the induction therapy with amphotericin B and flucytosine [43], the total cost of treatment is $390 M. This cost is approximately 8-fold the cost necessary to vaccinate the entire ADH population of sub-Saharan Africa. This is without considering the healthcare costs associated with hospitalization, although this will vary significantly from country to country and from hospitals to hospitals.…”

Same Day Antiretroviral Therapy Initiation, Prevalence and Co-factors of Advanced HIV Disease in an African Population- A 1 Year Report

“…Advanced HIV disease (AHD) is associated with the occurrence of comorbidities, increased cost of hospital care and higher mortality, usually within the first six months of initiating HAART [17]. In the context of the associated burden of AHD, understanding the magnitude of advanced HIV disease in our healthcare setting and the associated factors that influence its occurrence is vital for resource management, provision of quality healthcare to improve the health status of PLHIV and reduction in mortality.…”