- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT02624453
Pre-Antiretroviral Therapy (ART) Cryptococcal Antigen Screening in AIDS (PreCASA)
Implementation and Evaluation of a Screening Strategy to Reduce Morbidity and Mortality Due to Cryptoccocal Meningo-encephalitis in ART Naive AIDS Patients With <100 CD4 Count at the Day Hospital of the Yaounde Central Hospital, Cameroon
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Cryptococcal meningitis (CM) is a leading cause of death in AIDS patients in much of the developing world, responsible for up to 500,000 deaths each year in sub-Saharan Africa alone. Introduction of antiretroviral therapy (ART) has reduced the number of cases of cryptococcal meningitis in the developed world. Unfortunately, in many low resource settings, patients continue to present late to ART treatment programs with advanced immunosuppression, and many die of HIV-related illness in the weeks just prior to, and months following, initiation of ART. Cryptococcal meningitis causes many of these deaths, and is also a heavy burden on healthcare facilities. Treatment of the disease remains inadequate, with an acute mortality of between 20 and 50%, even with the best current treatment.
Many of these cases of cryptococcal meningitis may be preventable. Recent research has shown that routine screening for sub-clinical infection, using a simple test (cryptococcal antigen or CRAG) in patients presenting to ART programmes, can identify which patients are at risk of developing cryptococcal meningitis. Once identified, these patients could then be given safe oral "pre-emptive" treatment to prevent them developing a severe form of the disease. This strategy has many advantages over the alternative preventative measure, called generalised primary prophylaxis, which involves giving all profoundly immune depressed HIV-infected patients preventative treatment. Using a primary prophylaxis strategy, large numbers of patients are given medication, many of whom don't need it, and there are problems of cost and development of drug resistance and drug interactions. In a targeted strategy, only patients who benefit most from the treatment will be given medication.
The investigators propose to study the feasibility and effectiveness of CRAG screening and targeted pre-emptive treatment in patients entering ART treatment programmes in Yaoundé, Cameroon using a newly approved, easier to use, lateral flow format dipstick test (LFA). In the planned study, 400 patients will be screened using the CRAG test prior to starting ART. Patients with a positive cryptococcal antigen will be consented for a lumbar puncture (LP) for cerebrospinal fluid (CSF) analysis, and, if found to have cryptococcal meningitis, and eligible, they will be randomised and included in the complementary clinical trial "Advancing Cryptococcal Treatment in Africa" (ACTA) [ISRCTN45035509, ANRS12275] and treated according to the study protocol. Positive cryptococcal antigen patients with no evidence of neurological disease following lumbar puncture, or who decline a diagnostic LP will receive a tapering course of fluconazole. Cryptococcal antigen negative patients will not receive any additional antifungal therapy. All CRAG screened patients will be started on standard ART 2 to 4 weeks after screening and followed for up to 1 year, depending on antigen status, to determine whether any patients go on to develop clinical cryptococcal meningitis.
General objective
- To implement and evaluate systematic cryptococcal antigen screening as a strategy to reduce cryptococcal meningoencephalitis morbidity and mortality among HIV-infected patients initiating antiretroviral therapy at less than 100 CD4 cell counts at the Day Hospital of the Yaoundé Central Hospital in Cameroon
Specific objectives
- To determine the prevalence of cryptococcal antigenaemia and/or antigenuria among HIV-infected patients presenting with less than 100 CD4 cell count
- To determine the prevalence of laboratory confirmed cryptococcal meningoencephalitis among patients found to be CRAG positive
- To determine the incidence of newly diagnosed, and relapsing, laboratory confirmed cryptococcal meningitis in the first year after starting ART in all screened patients.
- To determine mortality within the first year of ART among patients screened for CRAG
Study design and number of patients A prospective cohort study of 400 ART naive patients presenting at entry of ART programme with less than 100 CD4 cell count/ml will be screened for CRAG using LFA in serum and urine and followed up for one year.
Study interventions Main intervention of the study will be cryptococcal antigen (CRAG) screening. All eligible patients will be screened at baseline using an LFA, a point of care (POC) dipstick test, on serum and/or plasma, and urine. Aliquots will be saved for later titering of CRAG positive samples. All subsequent treatments and patient management will be according to local guidelines and/or internationally accepted best practice standards.
Subsequent management Cryptococcal antigen negative participants: All CRAG negative participants will commence ART once counselling and pre-ART work-up are complete within an estimated time of 2 weeks in accordance with current Cameroon National AIDS control programme guidelines. There will be no further interventions. The participant will be seen at the outpatient clinic on the 2nd and 4th weeks following screening, then routinely according to the day hospital roster, and finally, every three months up to one year after the date of screening.
Cryptococcal antigen positive participants: All CRAG positive participants will have a careful symptom screen (headache/altered mental status), and will be asked to consent for an LP for CSF analysis: If cryptococcal meningitis is diagnosed by Indian ink and/or culture, and the patients is eligible, the patient may be included in the clinical trial "Advancing Cryptococcal Treatment in Africa" (ACTA) and treated according to ACTA protocol. If a patient is ineligible, or declines to be included in the ACTA trial, they will be treated with short course amphotericin B (one week) combined with oral fluconazole 800mg/day for two weeks, then 8 weeks of fluconazole 40mg/day and 200mg/day thereafter.
If LP is negative for cryptococcal meningitis (or LP refused), patients will receive Fluconazole 800 mg/day for 2 weeks then 400 mg/day for 8 weeks then 200 mg/day (based on current best practice).
Patients will commence ART (efavirenz based) 2-4 weeks after starting antifungal therapy, in accordance with current Cameroon National AIDS control programme guidelines. Follow-up will be for one year. Patients will be seen at the outpatient clinic every two weeks for the first ten weeks, then at three month intervals. During the outpatient visits, in case of any opportunistic infection occurrence, they will be managed according to local current practice of the Day Hospital. Women of child-bearing age will be proposed contraception (preferably barrier methods) during the period of follow up.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
Central Region
-
Yaounde, Central Region, Cameroon, 87
- Day Hospital of the Yaounde Central Hospital
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Age ≥ 18years
- HIV 1 and 2 infected but naïve to ART
- CD4 cell count less than 100 cells/ml
- No documented past history of cryptococcal meningoencephalitis
- Acceptance to participate in the study
- Ambulatory/out patients.
Exclusion Criteria:
- Patients on ART
- Pregnant patients
- Patients with other severe AIDS-associated opportunistic infections
Study Plan
How is the study designed?
Design Details
- Primary Purpose: SCREENING
- Allocation: NON_RANDOMIZED
- Interventional Model: PARALLEL
- Masking: NONE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
EXPERIMENTAL: IMMY LFA positive patients
HIV positive patients who will be positive for cryptococcal antigen (by the IMMY LFA test) would be consented for lumbar puncture in search of cryptococcal meningitis (CM).
If CM is not confirmed, they would be prescribed pre-emptive fluconazole based therapy at 800mg/day for two weeks (placed on antiretroviral therapy two weeks after screening for cryptococcal antigen), then 400mg/day for 8 weeks and thereafter 200mg/day until CD4 counts increases beyond 200cells/ml.
(CM confirmed cases will be referred to the ACTA trial ISRCTN45035509)
|
Pre-emptive fluconazole therapy at 800mg/day for two weeks, then 400mg/day for eight weeks, and then 200mg/day thereafter till CD4 count goes beyond 200cells/ml
Other Names:
First line anti-retroviral therapy according to Cameroon national guidelines for the management of HIV/AIDS
Other Names:
|
ACTIVE_COMPARATOR: IMMY LFA negative patients
HIV positive patient who will be negative for cryptococcal antigen (by the IMMY LFA test) would not be consented for lumbar puncture, will be placed immediately on antiretroviral therapy immediately after screening for cryptococcal antigen and would not be placed on fluconazole pre-emptive therapy.
|
First line anti-retroviral therapy according to Cameroon national guidelines for the management of HIV/AIDS
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Prevalence of cryptococcal antigenaemia and antigenuria
Time Frame: at inclusion
|
Prevalence of cryptococcal antigenaemia and antigenuria in HIV patients with CD4 ≤ 100 cells/µL at the Day Hospital of the Yaoundé Central Hospital
|
at inclusion
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Baseline prevalence of laboratory confirmed Cryptococcal Meningitis
Time Frame: at inclusion
|
Baseline prevalence of laboratory confirmed Cryptococcal Meningitis among patients screened positive for Cryptococcal antigen
|
at inclusion
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Incidence of laboratory confirmed cryptococcal meningitis in the first year
Time Frame: first year of antiretroviral therapy initial
|
Incidence of laboratory confirmed cryptococcal meningitis in patients screen cryptococcal antigen positive in the first year of anti-retroviral therapy
|
first year of antiretroviral therapy initial
|
Incidence of newly diagnosed and relapsing in all patients in the first year
Time Frame: first year of antiretroviral therapy initiation
|
Incidence of newly diagnosed and relapsing, laboratory confirmed, cryptococcal meningitis in the first year after starting ART in patients screened for cryptococcal antigen.
|
first year of antiretroviral therapy initiation
|
Incidence of mortality within the first year
Time Frame: first year of antiretroviral therapy initiation
|
Incidence of mortality within the first year of antiretroviral therapy among cryptococcal antigen screened patients
|
first year of antiretroviral therapy initiation
|
Collaborators and Investigators
Investigators
- Principal Investigator: Olivier Lortholary, MD, PhD, Hôpital Universitaire Necker-Enfants Malades, Molecular Mycology Unit, Institut Pasteur of Paris, and Paris Descartes University, Paris, France
- Principal Investigator: Elvis Temfack, MD, MSc, Douala General Hospital, Douala, Cameroon and Paris Descartes University, Paris, France
- Study Director: Thomas Harrison, MD, Infectious Disease Unit, St George's University of London, London, United Kingdom
- Study Director: Charles Kouanfack, MD, PhD, Day Hospital, Yaoundé Central Hospital, Yaoundé, Cameroon
Study record dates
Study Major Dates
Study Start
Primary Completion (ANTICIPATED)
Study Completion (ANTICIPATED)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (ESTIMATE)
Study Record Updates
Last Update Posted (ACTUAL)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
- Central Nervous System Diseases
- Nervous System Diseases
- Infections
- Central Nervous System Infections
- Bacterial Infections and Mycoses
- Mycoses
- Meningitis, Fungal
- Central Nervous System Fungal Infections
- Cryptococcosis
- Meningitis
- Meningitis, Cryptococcal
- Physiological Effects of Drugs
- Molecular Mechanisms of Pharmacological Action
- Anti-Infective Agents
- Antiviral Agents
- Enzyme Inhibitors
- Hormones, Hormone Substitutes, and Hormone Antagonists
- Cytochrome P-450 Enzyme Inhibitors
- Hormone Antagonists
- Antifungal Agents
- Steroid Synthesis Inhibitors
- 14-alpha Demethylase Inhibitors
- Cytochrome P-450 CYP2C9 Inhibitors
- Cytochrome P-450 CYP2C19 Inhibitors
- Fluconazole
- Anti-Retroviral Agents
Other Study ID Numbers
- ANRS 12312 PreCASA
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
Clinical Trials on Cryptococcal Meningitis
-
Matinas BioPharma Nanotechnologies, Inc.University of MinnesotaNot yet recruitingCryptococcal Meningitis
-
Makerere UniversityGilead Sciences; University of MinnesotaRecruitingCryptococcal MeningitisUganda
-
Matinas BioPharma Nanotechnologies, Inc.University of MinnesotaCompletedCryptococcal MeningitisUganda
-
TTY BiopharmUnknownCryptococcal MeningitisTaiwan
-
Novartis PharmaceuticalsTerminatedCryptococcal MeningitisSouth Africa
-
Novartis PharmaceuticalsTerminatedCryptococcal MeningitisUnited States
-
University of MinnesotaNational Institute of Neurological Disorders and Stroke (NINDS); Medical Research... and other collaboratorsCompletedCryptococcal Meningitis | Fungal MeningitisUganda
-
Peking Union Medical College HospitalCSPC Ouyi Pharmaceutical Group Co., Ltd.Not yet recruiting
-
University of Pharmacy, YangonCompletedCryptococcal MeningitisMyanmar
-
University of ZimbabweCenters for Disease Control and PreventionCompletedCryptococcal MeningitisZimbabwe
Clinical Trials on Fluconazole
-
AstraZenecaCompletedAsthmaUnited States, Canada, Denmark, France, Italy, Sweden, United Kingdom, Belgium, Taiwan, Brazil, Poland, Russian Federation, Spain, Germany, Argentina, Colombia, Mexico
-
National Hospital for Tropical Diseases, Hanoi,...Centers for Disease Control and Prevention; Hospital for Tropical Diseases,...UnknownHIV/AIDS | Mycosis Fungoides | Cryptococcosis | Cryptococcal Meningitis | Opportunistic Infections, HIV Related | Mycosis; OpportunisticVietnam
-
Radboud University Medical CenterSt. Antonius HospitalCompletedObesity | Candidiasis | Invasive Fungal Infections | FluconazoleNetherlands
-
Daniel BenjaminPediatric Pharmacology Research Units NetworkCompletedCandidiasisUnited States
-
BayerCompletedPharmacology, ClinicalGermany
-
PfizerCompleted
-
Anders Rane, MD, PhD, Senior professorKarolinska University HospitalCompletedBacterial Infections and Mycoses | Ductus Arteriosis, PatentSweden
-
Makerere UniversityGilead Sciences; University of MinnesotaRecruitingCryptococcal MeningitisUganda
-
F2G Biotech GmbHThe Clinical Trials Centre Cologne; Klinik für Hämatologie, Aachen; Medizinische...Withdrawn
-
Benha UniversityRecruiting