1. Implementing CRAG Screening among HIV Patients Initiating ART in Rural HIV Clinics with Regular Absence of CD4 Testing Services in Tanzania
Gladys Mbwanji
Diana Faini, Amina Nyuri, Andrew Katende, Aneth V Kalinjuma, Dorcas Mnzava, Maja Weisser, David Boulware,Emilio Letang, on behalf of the KIULARCO Study Group

2. AIMS
To determine the CRAG prevalence in Kilombero district, rural southwest of Tanzania.
To demonstrate feasibility of integrating point -of- care CRAG screening and pre-emptive antifungal therapy in routine HIV care in rural clinics regardless of availability of CD4 testing facilities.
To demonstrate survival improvement for cryptococcal meningitis after implementation of optimal therapy at the district’s referral center.

3. Study area and recruitment sites
METHODS
Summary of the CRAG screening algorithm
Study area and recruitment sites

4. RESULTS Variable n % CRAG Testing site (n = 943) 514 54.5 429 45.6
Patients from peripheral clinics
514
54.5
Patients from referral hospital
429
45.6
CRAG prevalence by testing site 45
4.8
From peripheral clinics (no CD4) 24
4.7
From referral center (CD4 guided lab-reflex CRAG testing) 21
4.9
CSF CRAG
Positive
46.7
Negative 20
44.4
LP not done 4
8.9
Treatment, CRAG+ no CM (n=24)
No fluconazole 3
12.5
2 wks of fluconazole Induction course 16
66.7
2wks fluconazole induction +8wks consolidation 10
41.7
ART 11
45.8
Outcomes at 6mo CRAG+ no CM (n=24)
Died 17
70.8
Alive 7
29.2

5. RESULTS
Variable n %
Presence of neurological symptoms among those with meningitis (n=21)
Yes 18
85.7
None 3
14.3
Treatment among those with meningitis (n=21)
Fluconazole monotherapy
Fluconazole + short course Ampho B
ART 13
61.9
Cumulative Mortality Incidence among those with meningitis
2 weeks 4
19.0
10 weeks 9
42.9
6 months

6. CONCLUSIONS
Our CRAG screening algorithm tailored for rural Tanzanian HIV clinics was effective in improving cryptococcal detection among HIV patients enrolling into care in spite the of lack of CD4 testing services Universal CRAG screening at the time of ART initiation is a feasible and cost-effective strategy that could maximize clinical outcomes in rural sub-Saharan Africa only if coupled with a reliable governmental supply of fluconazole.