Immunodeficiency Virus Patients in Rural Tanzania: A Preventable Cause of Early Mortality

Background. Cryptococcal meningitis is a leading cause of death in people living with human immunodeficien-cy virus (HIV)/acquired immune deficiency syndrome. The World Health Organizations recommends pre-antire-troviral treatment (ART) cryptococcal antigen (CRAG) screening in persons with CD4 below 100 cells/µL. We assessed the prevalence and outcome of cryptococcal antigenemia in rural southern Tanzania. Methods. We conducted a retrospective study including all ART-naive adults with CD4 <150 cells/µL prospec-tively enrolled in the Kilombero and Ulanga Antiretroviral Cohort between 2008 and 2012. Cryptococcal antigen was assessed in cryopreserved pre-ART plasma. Cox regression estimated the composite outcome of death or loss to fol-low-up (LFU) by CRAG status and fluconazole use. Results. Of 750 ART-naive adults, 28 (3.7%) were CRAG-positive, corresponding to a prevalence of 4.4 % (23 of 520) in CD4 <100 and 2.2 % (5 of 230) in CD4 100–150 cells/µL. Within 1 year, 75 % (21 of 28) of CRAG-positive and 42 % (302 of 722) of CRAG-negative patients were dead or LFU (P <.001), with no differences across CD4 strata. Cryp-tococcal antigen positivity was an independent predictor of death or LFU after adjusting for relevant confounders (haz-ard ratio [HR], 2.50; 95 % confidence interval [CI], 1.29–4.83; P =.006). Cryptococcal meningitis occurred in 39 % (11 of 28) of CRAG-positive patients, with similar retention-in-care regardless of meningitis diagnosis (P =.8). Cryptococca