Abstract
Background
Cryptococcal meningitis (CM) causes 13%–20% of deaths among people living with HIV (PLHIV) globally. We examined the cost-effectiveness of improving access to CM diagnostics and treatment among PLHIV 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.
