Background
Cryptococcal antigen (CrAg) screening and pre-emptive treatment reduces risk of HIV-associated cryptococcal meningitis (CM) and death. Understanding the pathway to care following serum CrAg (sCrAg) screening is crucial for improving screening practices for people with advanced HIV disease.
Methods
We conducted structured interviews and collated hospital and laboratory data about patients with HIV-associated symptomatic CM at two tertiary-level hospitals in Johannesburg in South Africa, following informed consent. If done, prior sCrAg results were obtained from the Laboratory Information Management System. Participants were asked about their pathway to care prior to presentation.
Results
Among 126 participants with symptomatic CM (median CD4 count 24 cells/uL, IQR 9 – 52), 33% (41/126) of participants had ever undergone sCrAg screening prior to hospital admission, of whom 59% (24/41) had a positive result. Of those with available data, 74% (17/23) had no CM symptoms at the time of sCrAg testing and the average delay until symptom onset was 22 days (range 1 – 509). Of those without symptoms, 93% (13/14) visited a healthcare provider following testing, however only 22% (2/9) were known to receive any fluconazole prior to hospitalisation. Of those who did not take fluconazole, 17% (1/6) declined fluconazole, 17% (1/6) were referred for LP without fluconazole, and 67% (4) were seen by a healthcare provider but neither fluconazole nor LP were offered.
Conclusions
Around a third of participants had sCrAg screening prior to presentation with symptomatic CM and almost two thirds of these results were positive. The majority of participants who were sCrAg positive did not have any symptoms of meningitis at the time of sCrAg testing. Overall, 14% of all patients presenting with symptomatic crypotococcal meningitis had previously had asymptomatic cryptococcal antigenaemia. Most asymptomatic sCrAg-positive patients did not receive fluconazole or have a LP, despite accessing healthcare services.
This study highlights missed opportunities for reducing the incidence of CM and death in patients with advanced HIV disease, despite the reflexive CrAg screening programme in South Africa. Efforts to improve health worker and patient understanding around CrAg screening and recommended management are essential.
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