Vietnam Cryptococcal Retention in Care Study (CRICS) - Version 2.1
Conditions: HIV/AIDS, Cryptococcal Meningitis, Opportunistic Infections, HIV Related, Cryptococcosis, Mycosis; Opportunistic, Mycosis Fungoides
Sponsor: National Hospital for Tropical Diseases, Hanoi, Vietnam

Cryptococcal Retention In Care Study (CRICS) - Protocol Ver 2.1 - 7 January 2017 
 
Vietnam Cryptococcal Retention in Care 
Study (CRICS) 
 
 
Principal Investigator: 
Dr. Nguyen Van Kinh,  
National Hospital for Tropical Diseases 
78 Giai Phong Street, Dong Da district, Hanoi, Vietnam 
Email: kinhvaac@yahoo.com 
Point of contact/Study Coordinator:  
Dr. Vu Quoc Dat, Investigator - Study Coordinator 
National hospital for Tropical Diseases 
78 Giai Phong Street, Dong Da district, Hanoi, Vietnam 
Mobile: (+84) 93 2806 101 
Email: quocdat181@yahoo.com 
Identifying information:  
FOA No: GH-12-008 
Award Number: GH 000758  
Protocol version 2.1 
Date:  7 January, 2017 
 
 
 

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Table of contents 
Acronyms ................................................................................................................................... 4 
Protocol Summary ..................................................................................................................... 6 
Investigators and collaborating institutions ............................................................................... 9 
1. Introduction .......................................................................................................................... 10 
1.1 Background on cryptococcal infection .......................................................................... 10 
1.2 HIV and cryptococcal infection in Vietnam .................................................................. 11 
1.3 Diagnosis of cryptococcal infection in Vietnam ............................................................ 12 
1.4 Rationale for study ......................................................................................................... 12 
2. Study Objectives and Outcome Measures ........................................................................... 14 
3. Study Design and use LFA in study and non-study sites..................................................... 17 
4. Study population .................................................................................................................. 19 
4.1. Inclusion criteria: .......................................................................................................... 19 
4.2. Exclusion criteria: ......................................................................................................... 19 
5. Study sites ............................................................................................................................ 20 
6. Sample size calculation: ....................................................................................................... 23 
7. Study procedures .................................................................................................................. 24 
8. Study Implementation .......................................................................................................... 40 
8.1. CrAg screening program launch meeting ..................................................................... 40 
8.2 Pre-study training ........................................................................................................... 40 
8.3. Additional training in Phase 2 ....................................................................................... 41 
8.4 Monitoring visits ............................................................................................................ 42 
8.5 Management Meetings ................................................................................................... 43 
9. Specimen collection and processing .................................................................................... 43 
9.1. Sample collection .......................................................................................................... 43 
9.2. CD4 and CrAg Lateral Flow Assay (LFA) testing ....................................................... 44 
9.3. LFA in CSF during evaluation of CM .......................................................................... 46 
9.4. Quality Assurance for LFA and CD4 count ................................................................. 47 
9.5. Measurement of cryptococcal antigen titres ................................................................. 48 
10. Data Collection .................................................................................................................. 48 
10.1Patient variables ............................................................................................................ 50 
10.2. Cost and cost-effectiveness analysis data ................................................................... 52 
10.3. Talaromyces Manaffei Antigenemia in Stored Samples (Sub-study) ......................... 57 

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10.4.Datastorage .................................................................................................................. 58 
10.5. Data transfer ................................................................................................................ 59 
10.6 Data ownership, governance, sharing, dissemination .................................................. 60 
10.7 Data quality assurance ................................................................................................. 60 
11. Data Analysis ..................................................................................................................... 60 
12. Expanding implementation of CrAgscreening: Feasibility ................................................ 63 
13. Ethical considerations ........................................................................................................ 63 
13.1 Ethical review and informed consent ........................................................................... 63 
13.2. Waiver of consent (specific items) ............................................................................. 65 
13.3Confidentiality .............................................................................................................. 65 
13.4Benefits/Risks ............................................................................................................... 66 
14. Safety monitoring and adverse event reporting ................................................................. 67 
15. Sponsor Monitoring ........................................................................................................... 67 
16. Budget ................................................................................................................................ 70 
17. Implementation schedule ................................................................................................... 71 
References ................................................................................................................................ 72 
List of appendices .................................................................................................................... 74 
 
 
 

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Acronyms 
AE 
Adverse event 
AIDS 
Acquired Immune Deficiency Syndrome  
ALT or SGPT 
Alanine transaminase or serum glutamic-pyruvic transaminase 
ART 
Antiretroviral therapy 
ARV 
Antiretroviral 
AST or SGOT 
Aspartate transaminase or serum glutamic oxaloacetic transaminase 
CDC 
Centers for Disease Control and Prevention 
CI 
Confidence Interval 
CM 
Cryptococcal meningitis 
CNS 
CRA 
Central nervous system 
Clinical research associate 
CrAg 
Cryptococcal antigen 
CRF 
Case reporting form 
CSF 
Cerebrospinal fluid 
DEFF 
Design effect 
DOB 
Date of birth 
EFV 
Efavirenz 
ELISA 
Enzyme-linked immunosorbent assay 
HIV 
Human Immunodeficiency Virus 
HRQOL 
Health-related quality of life 
ICC 
Intraclass correlation coefficient 
ICER  
Incremental cost-effectiveness ratio 
ID 
Identification  
IRB 
Institutional Review Board 
IRIS 
Immune reconstitution inflammatory syndrome 
LFA 
Lateral flow assay 
LNMP  
Last Normal Menstrual Period 
LP 
Lumbar puncture 
MOH 
Ministry of Health 
NHTD 
National Hospital for Tropical Diseases 
NVP 
Nevirapine 
OI 
Opportunistic infection 

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OPC 
Outpatient clinic 
OUCRU 
Oxford University Clinical Research Unit in Vietnam 
PC 
Personal computer 
PEPFAR 
President's Emergency Plan for AIDS Relief  
PI 
Principal Investigator 
PLHIV 
People Living with HIV 
POC 
Point of contact 
QALY 
Quality-adjusted life-year 
SAE 
Serious adverse event 
SOC 
Standard of care 
SOP 
Standard Operating Procedure 
TB 
Tuberculosis 
TDH 
Tropical Diseases Hospital 
TmAg  
Talaromyces marneffei 
USD 
United States Dollar 
VAAC 
Viet Nam Administration of HIV/AIDS Control 
WHO 
World Health Organization 

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Protocol Summary 
Title:   
Vietnam Cryptococcal Retention in Care Study (CRICS). 
Purpose:  
This is a multicenter prospective cohort evaluation of the implementation of a 
cryptococcal antigen (CrAg) screening program at selected outpatient HIV 
clinics (OPCs) and network laboratories in Vietnam. The project will be 
implemented in 2 phases; 
Phase 1:From August 2015 to March 2017 [projected], HIV-infected patients 
who present for HIV care and undergo CD4 testing will be reviewed to 
determine the proportion of newly presenting patients with advanced disease 
(CD4 ≤100 cells/μL). Reflex CrAg screening will be performed using Lateral 
Flow Assay (LFA) for those with CD4≤100 cells/μL, per Vietnam national 
guidelines. 
 
Patients with CD4≤100 cells/μL who present for ART at a study OPCs—
CRICS Sites— will be recruited into the longitudinal study and followed up 
with assessments and the collection of routine and supplemental data for 12 
months or through September 2017 (whichever comes sooner).Those who are 
CrAg-positive, but have no features of central nervous system (CNS) disease, 
will be treated with high-dose fluconazole. Those with symptoms of CNS 
disease will be treated according to national guidelines. Survival, retention in 
care, and other clinical outcomes will be documented for patients who test 
CrAg-positive and are treated with fluconazole and those who test CrAg-
negative. Data from those tested at participating labs but not eligible for 
enrollment in the longitudinal study will contribute to estimation of the 
prevalence of CrAg. 
 
Phase 2: From April 2017[projected] to September 2017, we will perform a 
cost and cost-effectiveness analysis of CrAg screening, and continue screening 
as a routine service at existing sites and expand to additional sites 
(preferentially to hospitals affiliated with Phase 1 OPCs and to other OPCs 
whose CD4 testing is conducted at laboratories already conducting CrAg 
screening as part of Phase 1). CrAg tests will also be made available to screen 
all patients with CD4≤100 cells/μL including those who are treatment-
experienced. The test will also be made available for use among symptomatic 
patients for diagnostic purposes, including CSF and bloodtesting. We will 
monitor prevalence at each testing site, but screened patients will not be 
enrolled in longitudinal follow-up. Phase 2 will last for at least 6 months based 
on availability of funding and fluconazole for those who screen CrAg positive 
and the availability/stability of CD4 testing. [Note that follow up of patients 
enrolled in Phase 1 will continue during this time period, but is considered to 
be part of Phase 1 rather than Phase 2. Also, sites included in Phase 2 may 

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change over time as a results of the instability of CD4 testing (e.g., if 
participating laboratories stop conducting CD4 testing, those sites might no 
longer be included; if participating laboratories begin CD4 testing for other 
sites, those sites might be included).] 
Objectives: 
Primary objectives: 
• To estimate the proportion of people living with HIV (PLHIV) who have advanced 
disease (CD4 ≤ 100 cells/μL) at presentation to HIV care;  
• To determine the prevalence of CrAg-positivity among HIV infected patients with 
CD4 ≤ 100 cells/μL newly enrolled in care in Vietnam; 
• To determine clinical outcomes including common causes of mortality for PLHIV 
with CD4 ≤ 100 cells/μL who are enrolled in a programmatic rollout of screening for 
CrAg; 
• To estimate the 12-month mortality among two groups of HIV-infected patients with 
CD4 ≤ 100 cells/μL who are newly enrolled in care and treatment: 
o Those who are Crag-positive and are treated with high-dose fluconazole  
o Those who are CrAg-negative 
Secondary objectives: 
• To estimate the 12-month retention in care among two groups of HIV-infected 
patients with CD4 ≤ 100 cells/μL who are newly enrolled in care and treatment: 
o Those who are CrAg-positive and are treated with high-dose fluconazole  
o Those who are CrAg-negative 
• To identify challenges associated with implementation of routine plasma CrAg 
screening in clinics providing HIV care. 
• To disseminate lessons learned with participating sites to estimate the costs of 
implementing CrAg screening based on data collected at 22 OPCs participating in 
Phase 1and provider costs associated with cryptococcal meningitis (CM) treatment. 
• To conduct an incremental cost-effectiveness analysis of CrAg screening compared 
with a standard of care (SOC)(no CrAg screening, and treatment for symptomatic CM 
only). 
• To project potential cost savings from implementing CrAg screening and financial 
resources required to implement CrAg screening under different scale-up scenarios 
and for national rollout. To determine the prevalence Talaromyces (formerly 
Penicillium) marneffei antigenemia in stored sera and assess the impact of 
Talaromyces antigen (TmAg) positivity on mortality1 
                                                 
 
1 This objective is part of a sub-study and study procedures related to these objectives have a separate funding 
source. 

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Study participants and sites:  
HIV-positive ART naïve and experienced adults (>18 years of age) with a CD4 count 
≤100 cells/μL or WHO stage 3 or 5 enrolling in HIV care at 22 or more outpatient 
clinics (see Table 2) in the North, Middle, and South of Vietnam (Phase 1), 
laboratories serving patients from non-CRICS sites; HIV positive ART-naïve and 
experienced hospitalized patients who have CD4 ≤100 cells/μL or WHO stage 3 or 4 
disease or those with have symptoms of CNS infection (Phase 2). 
 
 

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Investigators and collaborating institutions 
Principal Investigators 
Assoc Prof. Nguyen Van Kinh, MD, National Hospital for Tropical Diseases 
Le Manh Hung, MD, Tropical Diseases Hospital (TDH) 
Co-Investigators 
National Hospital for Tropical Diseases (NHTD) 
Vu Quoc Dat 
Nguyen Thi Hoai Dung 
Tropical Diseases Hospital (TDH) 
Vo Minh Quang, MD 
Viet Nam Administration of HIV/AIDS Control (VAAC) 
Do Thi Nhan, MD 
Hanoi Medical University 
Vu Quoc Dat, MD (also with NHTD)  
Assoc. Prof. Hoang Van Minh, MD 
Bach Mai Hospital 
Pham Thi Thanh Thuy, MD, PhD 
Clinton Health Access Initiative 
Cao Thi Thanh Thuy, MD, M.Sc. 
U.S. Centers for Disease Control and Prevention 
 
Moses Bateganya, MD, MPH (Atlanta), SEV #7819: Team Lead, Care and Support DGHA, 
CDC-Atlanta. He is the technical point of contact for this study for the CDC- Atlanta office. 
Supports protocol development, site selection, will coordinate protocol submission, and 
contribute to the analysis and interpretation of data. 
 
Chutima Suraratdecha, PhD, MBA, SEV #17387: Lead, Health Economics and Finance 
Team, DGHT, CDC-Atlanta. She provides technical support on costs and cost-effectiveness 
analyses components during the protocol development and implementation, data analysis, 
interpretation, and dissemination of study results.  
 

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Ho Thi Van Anh, MD, M.Sc. (Vietnam), SEV #16337: Overall technical co-lead for this 
study in CDC-Vietnam. She is involved with protocol revision, training, implementation, 
oversight of study procedures and data, analysis, and dissemination. 
 
Hien Bui, MD, PhD (Vietnam), SEV#10221: Laboratory lead for this study in CDC-Vietnam. 
She is also involved broadly with protocol development, training, implementation, oversight 
of study procedures and data, analysis, and dissemination. 
 
Sheryl Lyss, MD, MPH (Vietnam), SEV #6750: Dr. Lyss is the medical advisor for the Care 
and Treatment teams and the Associate Director of Science for this study in CDC-Vietnam. 
She provides oversight for protocol development, training, implementation, oversight of 
study procedures and data, analysis, and dissemination. 
 
Brendan R Jackson MD MPH (Atlanta), Medical Epidemiologist, Mycotic Diseases Branch, 
SEV #1714.Provides subject matter expertise on cryptococcal disease and technical 
assistance to the study team as needed.   
 
Sheri Pals PhD (Atlanta), SEV #12092, Mathematical Statistician, provides statistical 
consultation to the study team as needed. 
 
CDC Project Officer 
Aaron Zee, MPH. Aaron is the project officer for this study and will provide technical 
support during implementation of the project, review of reports generated, participate in 
abstract and manuscript writing and monitor compliance with USG guidelines 
1. Introduction 
1.1 Background on cryptococcal infection 
CM is a fungal opportunistic infection (OI) that is one of the most common causes of 
death among human immunodeficiency virus (HIV)-infected persons [1]. In Southeast Asia, 
the prevalence of CM in HIV-infected patients presenting to care might be as high as 10-
20%; an estimated 120,000 cases of CM and 66,000 deaths attributable to CM occur in SE 
Asia each year; this exceeds mortality from HIV-associated tuberculosis [1].CM occurs not 
only before a patient is on antiretroviral therapy (ART), but also afterwards, as an immune 

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reconstitution inflammatory syndrome (IRIS) [2, 3]. The incidence of CM has declined in 
some settings for patients who have access to ART [4]. Benefits of ART in patients with HIV 
will remain suboptimal as long as significant co-morbidities exist. CM is among the 
significant causes of poor patient outcomes and discontinuation of care. Linkage to care and 
retention in an ART program in South Africa following an episode of CM was poor, in part 
because of high rates of mortality[5].  
Increasing access to ART, which has resulted in significant reduction in incidence of 
cryptococcal disease in some settings, has not uniformly reduced overall morbidity and 
mortality from CM in part due to late HIV testing and treatment and inability to diagnose the 
disease early. An estimated 17-30% of patients who develop CM do so after the initiation of 
ART[2, 3, 6], in the context of IRIS.  
Screening HIV-infected patients for early cryptococcal disease by detecting circulating 
cryptococcal antigen (CrAg) and subsequently treating them with fluconazole shows promise 
as a public health strategy to reduce death and disseminated disease [7], and potentially 
improve patient retention in care. Studies have demonstrated that CrAg is present in 
peripheral blood weeks to months before the development of meningitis[8]. Treatment at this 
stage may be accomplished using oral fluconazole; treatment for meningitis, however, 
requires a toxic medication (intravenous amphotericin B) with substantial resource utilization 
(toxicity monitoring, frequent lumbar punctures (LP), and hospitalization). Screening 
strategies that detect CrAg in blood before clinical meningitis develops have been shown to 
be highly cost-effective in Cambodia, Uganda, and Vietnam[7, 9, 10]. In 2011, the World 
Health Organization (WHO) recommended that screening for cryptococcal antigenemia be 
considered in areas with a high prevalence of cryptococcal disease, among high-risk patients 
(adults with CD4 counts <100cells/μL)[11]. As a result, several countries are now 
investigating the feasibility of implementing CrAg screening as part of HIV care. 
1.2 HIV and cryptococcal infection in Vietnam 
The HIV epidemic in Vietnam remains concentrated primarily among three key 
populations: people who inject drugs, men who have sex with men, and female sex workers. 
As of 30 November 2012, HIV cases had been reported in all 63 provinces of Vietnam, 98% 
of districts and 79.1% of communes with an estimated 208,866 people living with HIV 
(PLHIV), 59,839 acquired immunodeficiency syndrome (AIDS) cases, and 62,184 AIDS-
related deaths[12]. 

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Data on the overall burden of OIs including CM and mortality in Vietnam is limited. 
Cryptococcus was reported as the most common OI among HIV-infected persons in a study 
of patients presenting to a single hospital in Ho Chi Minh City [13].In that same study, 
Cryptococcus neoformans was the leading cause of fungal meningitis and fungemia and was 
associated with the highest mortality rate (16.8%) among OIs in HIV patients [13].In a study 
in a northeastern province of Vietnam during 2007—2010, two of 49 AIDS-related deaths 
were attributed to CM[14]. However, the data on prevalence of CM has not been reported.  
Only one retrospective study has evaluated CrAg prevalence in Vietnam. There appears 
to be some geographical variation across different regions; the estimated CrAg-
positivitywas6% in the South and 2% in North Vietnam[10]. The prevalence in the middle of 
Vietnam has not been determined. The reasons for differences in prevalence of cryptococcal 
disease between regions in Vietnam are not known but could be related to environmental or 
host factors. 
Vietnam is currently undergoing substantial changes in financing for and delivery of HIV 
services as funding is transitioned from international donors to national government sources. 
Additionally, as viral load monitoring is being rolled out, CD4 testing is being scaled down. 
Some laboratories now require patients to pay for CD4 testing, some have reported stock out 
of CD4 reagents or technical failures. Some laboratories have transitioned CD4 testing to 
other laboratories. 
1.3 Diagnosis of cryptococcal infection in Vietnam 
In Vietnam, the diagnosis of CM relies on clinical criteria, a positive cerebrospinal fluid 
(CSF) India ink stain or a positive CSF culture[15].However, clinics within Vietnam have 
variable abilities to conduct LP and CSF analysis. Historically, CrAg tests have not been 
utilized in countries such as Vietnam, due to cost and need for laboratory infrastructure and 
training. 
In July 2015, the Vietnam MOH released new guidance on HIV/AIDS management 
which currently recommends cryptococcal antigen screening among ART naïve patients with 
CD4< 100 cells/µL and pre-emptive therapy with fluconazole for those who are CrAg (+) 
[16]. 
1.4 Rationale for study 
In Vietnam almost 52.7% of PLHIV who started ART in 2010 had a CD4 count of less 
than 100 cells/μL[17], and were therefore at risk of development of severe OIs including CM. 

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Knowledge of OIs and mortality among patients presenting with late-stage HIV will be useful 
for clinical care and service delivery. In particular, implementing new prevention strategies 
for CM are critical to improve the success of HIV treatment programs. 
The evaluation of this cryptococcal screening program will provide an assessment of the, 
survival, other clinical outcomes, and retention in care in of patients with CD4 count ≤100 
cells/μL who test positive and negative for plasma CrAg; an estimate of the prevalence of 
cryptococcal antigenemia in Vietnam; and also an understanding of clinical outcomes in HIV 
patients with CD4 count ≤100 cells/μL. 
We hypothesize that implementing plasma CrAg screening in clinics providing routine 
HIV care will enable identification of Vietnamese adult patients with advanced HIV (CD4 
≤100cells/μL) who have early cryptococcal disease, enable prompt preemptive treatment with 
high-dose fluconazole, and improve survival. The program will demonstrate the feasibility. 
The program will provide important programmatic information and economic data for the 
scale-up of CrAg screening and treatment in the rest of Vietnam and provide additional 
information on the burden of OIs and causes of mortality among patients presented with late-
stage HIV. 

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2. Study Objectives and Outcome Measures 
Table 1. Study objectives and outcome measures 
Primary objectives 
Outcome measures 
1. To estimate the proportion of people 
living with HIV (PLHIV) who have 
advanced disease (CD4 ≤ 100 cells/μL) at 
presentation to HIV care 
• Proportion of HIV-infected adults who 
have CD4 count ≤ 100 cells/μL 
 
2. To determine the prevalence of CrAg-
positivity among HIV-infected patients 
with CD4 ≤100 cells/μL 
• Proportion of patients who are CrAg-
positive among all HIV-infected adults 
who have CD4 count ≤ 100 cells/μL 
3. To determine clinical outcomes including 
common causes of mortality for PLHIV 
with CD4 ≤ 100 cells/μL who are 
enrolled in a programmatic rollout of 
screening for CrAg 
• Reported causes of death 
• Proportion of patients with HIV-
related hospitalizations at 6 and 12 
months 
• Proportion of patients with new AIDS-
defining OIs/conditions at 6 and 12 
months 
4. To estimate the 12-month mortality 
among two groups of HIV-infected 
patients with CD4 ≤ 100 cells/μL who are 
enrolled in care and treatment:  
• Those who are CrAg-positive and 
are treated with high-dose 
fluconazole; 
• Those who are CrAg-negative. 
• Twelve (12) month all-causes and 
CM-related mortality among patients 
who screen CrAg-positive and CrAg-
negative 
 
 

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Secondary objectives 
Outcome measures 
5. To estimate the 12-month retention in care 
among two groups of HIV-infected patients 
with CD4 ≤ 100 cells/μL who are newly 
enrolled in care and treatment: 
• Those who are CrAg-positive and 
are treated with high-dose 
fluconazole  
• Those who are CrAg-negative 
 
• Twelve (12) month retention 
among patients who screen 
CrAg-positive and CrAg-negative 
 
6. Identify challenges associated with 
implementation of routine plasma CrAg 
screening in clinics providing HIV care 
• Percentage of patients with CD4≤ 
100 cells/μL who are lost to 
follow-up or have incomplete 
documentation 
• % of patients with no 
documented clinic visit 30, 60, 
and 90 days after date of the 
scheduled clinic appointment 
7. To disseminate lessons learned with 
participating sites 
• Reflection and transition 
workshop  
8. To estimate the costs of implementing CrAg 
screening based on data to be collected at 22 
participating OPCs participating in Phase 1 
and provider costs associated with CM 
treatment. 
• Total costs and unit cost per 
person screened, per CrAg+ 
treated by site, lab facility type, 
and cost component 
9. To conduct an incremental cost-
effectiveness analysis of CrAg screening 
compared with a standard of care (no CrAg 
screening, and treatment for symptomatic 
CM only). 
• Incremental cost-effectiveness 
ratio (cost per CM death averted 
and cost per quality adjusted life 
year (QALY)) 

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10. To project potential cost savings from 
implementing CrAg screening and 
financial resources required to implement 
CrAg screening under different scale-up 
scenarios and for national rollout. 
• Total cost savings and amount of 
financial resources required to 
implement CrAg screening 
11. 
To determine the prevalence of 
Talaromyces marneffei antigenemia 
(TmAg) in stored CRICS samples using 
the Mannose phosphate isomerase 1 
(MP1) enzyme-linked immunosorbent 
assay (ELISA) 
• Proportion of stored samples that 
test positive for TmAg 
12. To assess the impact of TmAg positivity 
on mortality 
• Six (6) and twelve (12) month 
all-causes and TM-related 
mortality among patients who 
screen TmAg-positive and 
TmAg-negative 

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3. Study design and use LFA in study and non-study sites 
This is multicenter, prospective, cohort evaluation of a CrAg screening program among 
HIV-infected patients with CD4 ≤100 cells/μL who are newly enrolled in care at selected 
HIV OPCs in Vietnam, conducted in collaboration with the Vietnam Administration for 
HIV/AIDS Control (VAAC). The evaluation will be implemented in 2 phases.  
Phase 1: Enrollment in the longitudinal study will take place from August 2015-March 
2017 [projected approval of the protocol amendment for Phase 2]. In Phase 1, patients with 
CD4≤100 cells/μL who are newly presenting for HIV care at 22 outpatient sites in the North, 
Middle, and South of Vietnam have been screened for cryptococcal disease by testing their 
plasma for CrAg using LFA and enrolled into the study for 12 months’ follow-up. 
Phase 2 will start in April 2017 or when the protocol amendment is approved and will 
continue for up to 3-6 months. After 3-6 months, transition of the program will be discussed 
with VAAC for continued programmatic rollout. . During this phase we will perform a cost 
and cost-effectiveness analysis of CrAg screening and continue CrAg screening as a routine 
service without enrollment in prospective follow up. CrAg tests will be made available to 
screen patients with CD4≤100 cells/μL including those who are treatment experienced in 
selected existing and additional sites, and to screen hospitalized patients with CD4 ≤100 
cells/μL and/or suspected CNS infections in hospitals affiliated with the CRICS OPCs. CrAg 
testing will also be used for diagnostic purposes among patients with symptoms or signs of 
meningitis. We will monitor the prevalence during Phase 2 but screened patients will not be 
followed up prospectively in the study. As CrAg screening is a WHO and Vietnam MOH 
national recommendation, it is considered SOC for persons with advanced HIV (CD4≤100 
cells/μL), and reflexive testing does not require informed consent. Testing will be expanded 
during Phase 2 to screen other patients at selected Phase 1 and additional sites without 
enrolling them into follow up. 
 
Use of LFA at study and non-study facilities and laboratories in Phase 2 
CrAg screening will continue to be performed upon the completion of Phase 1. However, 
screened patients will not be followed prospectively. 
To facilitate the implementation of CrAg screening nationally, laboratory staff and 
clinical providers will be made aware of the availability of LFA for screening and diagnosis. 
CRICS laboratories will use the LFA provided by the study to perform reflexive CrAg 

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screening with study LFA on specimens from patients with CD4≤100 cells/μL from OPCs 
included in Phase 1 and from other OPCs that are in their network, i.e., that routinely transfer 
specimens to these labs for CD4 count testing. LFA kits will also be used as needed for 
outpatient and inpatient medical wards affiliated with the participating laboratories for 
screening HIV patients with CD4≤100 cells/μL or with WHO stage 3 or 4 disease and for 
diagnostic purposes among patients with suspected meningitis. 
During Phase 2, for patients who test CrAg positive, participating laboratories will inform 
the corresponding OPCs or inpatients wards of the results as soon as possible. The patient’s 
primary providers will be responsible for discussing results with the patients and for 
prescription of fluconazole and follow up according to national guidelines. If the patient’s 
OPC or hospital does not have fluconazole available (because of the current uncertainty of 
the supply of medications for opportunistic infections during the transition of financing from 
international donors to Vietnamese sources), fluconazole for identified CrAg positive patients 
will be provided by the study. 
Numbers of tests and results will be documented through participating CRICS labs and 
tallied and will be used to in estimating the CrAg prevalence. 
 
Enrollment in the follow-up study 
In Phase 1, enrollment in the longitudinal cohort will be offered to eligible patients who 
have CD4≤100 cells/µL enrolled at and plan to receive ongoing outpatient care at one of the 
selected study OPCs (Table 2). Those who test plasma CrAg-positive and have no symptoms 
of meningitis will be treated with high-dose fluconazole. Study participants will be followed 
from the time of plasma CrAg screening for a minimum of 6 months and up to12 months 
depending upon when they are recruited with respect to the study expected duration. Routine 
clinical data will be abstracted from medical records and supplemental data will be collected 
to determine treatment outcomes and related factors. Fluconazole will be provided by the 
study for patients enrolled in the follow-up program during Phase 1 for the duration of the 
study. For those who tested CrAg-positive and are still receiving maintenance fluconazole at 
the end of their longitudinal follow up, fluconazole will be provided through routine sources. 
In Phase 2,screened patients will not be followed up prospectively. However, fluconazole 
supply for identified CrAg-positive patients will be provided by the project if patients do not 
otherwise have access through their OPCs. 

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Definition of end points 
Retention in care: Patient known to be alive and have visited the clinic in the prior 90 days. 
Dead: Patient confirmed or reported to have died. 
Lost to follow-up: Follow up will be described in two ways. From the time of enrollment in 
the study and from ART initiation (routinely collected through retention national indicators).  
Patients have not returned to the clinics > 90 days from the last clinical appointment for those 
who initiated ART and > 6 months for those who have not initiated ART without any follow 
up contacts with their OPCs, have not been reported or confirmed dead, or known to have 
transferred to other clinics.  
4. Study population 
Eligibility criteria for Phase 1.  
4.1. Inclusion criteria: 
• Aged ≥ 18 years (having passed 18th birthday using Western calendar) 
• Confirmed HIV infection using National Testing Algorithm 
• CD4 ≤100 cells/μL 
• Able to provide written informed consent 
• Enrolled at and plan to receive ongoing outpatient care at one of the selected study 
OPCs 
4.2. Exclusion criteria: 
• History of prior CM 
• Receipt of systemic antifungal medication for more than 4 consecutive weeks within 
the past 6 months 
• Receipt of ART for more than 4 consecutive weeks within the past year 
• For CrAg-positive patients only: Known to be currently pregnant or planning to 
become pregnant during the study period  
Eligibility criteria for phase 2 
In Phase 1, patients were prescreened for eligibility to enroll in the longitudinal 
study, and CrAg testing was only performed on patients who met study eligibility criteria (as 
above) and for whom the clinician filled out a CrAg requisition form as part of the study.  
 

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Phase 2, has no longitudinal component, and CrAg screening will be implemented in a 
programmatic manner. The national guidelines recommend “screening for serum 
Cryptococcus neoformans antigen (CrAg) in adults who have not received ART with CD4 
count below 100 cells/μL.”  Thus, in phase 2, as per national guidelines, CrAg screening will 
be performed reflexively on all HIV positive ART Naïve and experienced adults with 
CD4<100 cells/μL or with WHO stage 3 or 4 who are enrolled for care at the CRICS OPCs 
or are receiving inpatient or outpatient care at a facility whose CD4 testing is conducted by 
one of the CRICS labs. CrAg screening will also be done if requested by providers based on 
CD4 or clinical criteria.  
 
5. Study sites 
Phase 1 
Eligible patients will be enrolled consecutively from 22 participating OPCs. See sites by 
region and number of patients starting ART in 2013, an indication of the volume of patients 
at each site. Program data are not disaggregated by CD4 < or >100cells/μL; approximately 
1/3 to ½ are expected to have CD4 <100 cells/μL [16]. The sites have been purposefully 
selected to represent: (1) district, provincial or national level; (2) facilities able to provide 
primary or tertiary care; (3) rural, peri-urban, and urban location; (4) facilities with a 
sufficient number of patients; and (5) different capacity for diagnostic investigations. For 
logistical reasons, only two sites will be recruited from the middle of Vietnam, a reflection of 
the relatively lower prevalence of HIV and lower number of PLHIV and treatment facilities 
in this region. The prevalence of cryptococcal disease in this region has not been previously 
assessed and findings from these sites will help to determine if another prevalence study will 
be required. 
 
 
 
 

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Table 2.List of Phase 1 study sites by region and number of patients starting ART in 
2013 
 
Name of OPC 
Name of 
province 
Region 
Facility 
level of 
care 
Funder 
Estimated # 
of ART 
initiators in 
2013 
1 
Tropical Diseases 
Hospital  
Ho Chi Minh 
City 
South 
Provincial 
PEPFAR 
446 
2 
National Hospital for 
Tropical Diseases 
Hanoi 
North 
National 
PEPFAR 
366 
3 
Binh Thanh District 
Outpatient Clinic 
Ho Chi Minh 
City 
South 
District 
PEPFAR 
236 
4 
Health Center of Hoc 
Mon District 
Ho Chi Minh 
City 
South 
District 
PEPFAR 
231 
5 
An Giang Provincial 
Hospital 
An Giang 
South 
Provincial 
PEPFAR 
214 
6 
A Hospital 
Thái Nguyên 
North 
Provincial 
Global Fund 
212 
7 
Bach Mai Hospital 
Hanoi 
North 
National 
PEPFAR 
208 
8 
District 8 Hospital  
Ho Chi Minh 
City 
South 
District 
PEPFAR 
183 
9 
Binh Chanh District 
Hospital 
Ho Chi Minh 
City 
South 
District 
PEPFAR 
183 
10 
Thu Duc District 
Outpatient Clinic 
Ho Chi Minh 
City 
South 
District 
PEPFAR 
171 
11 
Binh Duong Provincial 
Hospital 
Bình Dương 
South 
Provincial 
PEPFAR 
164 
12 
Tan Binh Preventive 
Medicine Center 
Ho Chi Minh 
City 
South 
District 
PEPFAR 
162 
13 
Vinh Phuc Provincial 
AIDS Center 
Vĩnh Phúc 
North 
Provincial 
Global Fund 
162 
14 
Quang Ninh Provincial 
Hospital  
Quảng Ninh 
North 
Provincial 
PEPFAR 
159 
15 
Tan Chau District 
Hospital 
An Giang 
South 
District 
PEPFAR 
142 
16 
Thanh Hoa Provincial 
AIDS Center 
Thanh Hóa 
Mid 
Provincial 
Global Fund 
140 
17 
Mai Son Hospital 
Sơn La 
North 
District 
PEPFAR 
132 
1 
District 4 Outpatient 
Clinic 
Ho Chi Minh 
City 
South 
District 
PEPFAR 
130 
19 
Nghe An Provincial 
Hospital 
Nghệ An  
Mid 
Provincial 
PEPFAR 
128 
20 
Binh Tan Preventive 
Medicine Center 
Ho Chi Minh 
City 
South 
District 
Global Fund 
110 
21 
Ha Dong Hospital 
Hanoi 
North 
District 
PEPFAR 
97 
22 
09 Hospital 
Hanoi 
North 
Provincial 
National 
targeted 
program 
66 
 
Total 
 
 
 
 
4042 

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Phase 2: Types of study sites 
For purposes of this study and as described above we have characterized three potential types 
of sites: 
(i) CRICS sites- This includes the 22 OPCs participating in Phase 1. Based on number of 
CrAg-positive patients identified at given OPCs, resources, and logistics, CrAg screening 
may not continue at all 22 Phase 1 sites during Phase 2.  
(ii) Inpatient wards affiliated with the 22 OPCs- These wards are often co-located with the 
OPCs. Patients with CD4≤100 cells/µL or with WHO stage 3 or 4 will be screened for CrAg 
at the discretion of their providers. Patients with symptoms of meningitis will be tested for 
diagnostic purposes (blood and/or CSF) regardless of CD4 count.  
(iii) Expanded OPCs- Reflex CrAg screening will be expanded to additional OPCs 
(preferentially to OPCs whose CD4 testing is conducted at laboratories already conducting 
CrAg screening as part of Phase 1).  
Participation of sites and patients might not be consistent during Phase 2: 
• Because of transition of finances from international donors to Vietnamese sources 
and from CD4 to viral load monitoring, CD4 testing may be unstable: 
o Participating laboratories might temporarily run out of reagents 
o If CD4 machines break down, resources might or might not be available to 
repair them 
o Some laboratories might cease CD4 testing altogether 
When this happens, if a different laboratory assumes CD4 testing for a given OPC, 
CrAg screening at those OPCs might not continue if that laboratory has not been 
conducting CrAg screening. In these cases, CrAg screening will be performed when 
requested by the primary provider for those with WHO stage 3 or 4 or those with 
overt symptoms of meningitis. 
• If a given laboratory assumes CD4 testing for multiple other laboratories, the burden 
of CD4 testing might preclude CrAg testing. 
• Some laboratories might charge patients for CD4 testing. If the patient does not have 
health insurance or ability to pay for CD4 testing, individual patients might not 
receive CD4 testing (and then would not receive CrAg testing). 
 
Such sources of instability will be monitored as factors related to feasibility of CrAg 
screening. 

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6. Sample size calculation: 
The two primary outcomes of the study are 1) the estimate of the percentage of 
prescreened patients who have CD4≤100 cells/µL and 2) Of those with CD4≤100 cells/µL, 
the estimate of the percentage who are CrAg+. For these primary outcomes, data will come 
from both Phase 1 and Phase 2. From study initiation to October 31 2016 (approximately 13 
months), we prescreened 2,612participants, and 1068 of these had a CD4 ≤100 cells/µL. Of 
those, 957 enrolled, and 25(2.6%) were CrAg+. Assuming a similar enrollment rate (74 per 
month), upon the completion of Phase 1 (March 2017), we will have prescreened 3,014 
participants and would expect 1,232to have CD4≤100 cells/µL and 1,104 to be enrolled in the 
follow up study. Of these, we would expect approximately 29to be CrAg+.  
For Phase 2 (presumably from February 2017 to September 2017), plan to prescreen an 
additional 1,808 patients. Taking both data from Phase 1 and Phase 2 into account, we would 
expect to prescreen 4,822 patients and to document 1,972 patients with CD4≤100 cells/µL. In 
total, we would expect approximately 46 patients to be CrAg+.  
Table 3presents confidence limits for the two primary outcomes based on these assumptions 
and incorporating a design effect (DEFF) to account for the within-facility clustering of 
observations. The design effect is computed as [1+(m-1) ICC] where m is the average 
number of patients per facility and ICC is the intraclass correlation coefficient. There is no 
local data on which to base assumptions about the magnitude of the within-clinic correlation 
in Vietnam, but a recent publication reports intraclass correlation coefficients (ICCs) of about 
.02 or smaller for health-related variables in an HIV-positive clinic population in sub-Saharan 
Africa [4]. Taking data from Phase 1 into account only, for the first primary outcome, m is 
137 (3014/22) and for the second primary outcome, m is 56 (1,232/22). Taking data from 
both Phase 1 and Phase 2 into account, m is 219 (4822/22) and is 90 (1972/22) for the first 
and the second primary outcomes respectively.  
 
 

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Table 3.  Precision for primary study outcomes based on projected enrollment in Phase 
1 (through March2017) and Phase 1 + Phase 2 (projected through September 2017) 
 
Pre-
screened 
% with 
CD4≤100 
Design 
Effect 
95% 
confidence 
limits 
Number 
tested 
for 
CrAg 
% 
CrAg-
positive 
Number 
CrAg+ 
Design 
Effect 
95% 
confidence 
limits 
Phase 1 (projected through Dec 31, 2016) 
3,014 
40.9 
3.72 
37.5, 44.3 
1,232 
2.6 
29 
2.10 
1.30, 3.90 
Phase 1 + Phase 2 (projected through September 2017 among 22 study OPCs only) 
4,822 
40.9 
5.36 
37.7, 44.1 
1,972 
2.6 
46 
2.78 
1.40, 3.80 
 
Note: Confidence limits are inflated by a design effect of [1+(m-1)] where m is the average number 
of patients per facility and is the intraclass correlation coefficient. 
 
7. Study procedures 
7.1. CrAg Screening Implementation (Reflex testing, return of results, 
communicating results and enrolment into the prospective cohort) 
7.1.1. CrAg screening in study OPCs in Phase 1 
As CrAg screening is a WHO and Vietnam MOH national recommendation, it is 
considered SOC for persons with advanced HIV (CD4≤100 cells/µL), and reflexive testing 
does not require informed consent. All adult patients presenting for ART evaluation and who 
provide a sample for CD4 testing will be educated about the risks of OIs such as CM and 
tested for cryptococcal antigen in accordance with national guidance. They will be 
specifically informed about CrAg screening prior to their blood draw using a short script (See 
Appendix 1: Screening , Appendix 2A: Script informing patients of CrAg screening 
(English)and Appendix).  
Patients will be told that those with low CD4 whose CrAg results are positive will be 
contacted by the clinic to invite them back for an earlier appointment. Results of the CD4 and 
CrAg tests will be sent to the respective clinics within 24 hours of the tests, and made 
available to physicians (Appendix 15: CrAg Testing Request Form). Results of the CD4 and 
CrAg tests will be recorded daily into the evaluation logs at the participating laboratories and 
respective clinics (see Appendix and Appendix 16: CrAg testing log for the lab).  
Once the clinic receives the test results, OPC staff will be responsible for contacting the 
patients who are CrAg-positive by telephone with the results within 24 hour sand request 

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them to return to the clinic for an earlier appointment. Three attempts will be made to reach 
the patient by phone or Short Message Service (SMS) and if not reachable, the patient will be 
seen at his routine scheduled appointment which is normally within two weeks of the date of 
CD4 testing. When patients with CD4 ≤100 cells/µL return to the clinic, they will be 
informed of the results of both the CD4 and plasma CrAg testing. Procedures for the 
prospective cohort evaluation and data collection will be described. If the patient agrees to 
participate, s/he will sign the consent form for enrollment (see Appendix 3A: Inform Consent 
Form (English)) and will be assigned a study identification (ID) number. This will be 
considered a study visit since in routine practice, patients only return for their CD4 at the next 
scheduled visit, usually 1-2 weeks after that date of sample collection.  
7.1.2. CrAg screening in Phase 2 
In Phase 2, CrAg screening will be performed as a routine service, and physicians will not 
prescreen patients according to study eligibility criteria. Rather, all routine laboratory 
requisition forms from the participants sites will be pre-marked with a note to the laboratory 
to perform reflex CrAg screening on any specimen with a CD4 ≤100 cells/µL. Providers will 
have a checkbox to mark the indication for the CD4 test on the requisition form, i.e., whether 
the CD4 test is being ordered for (1) new enrollment; (2) routine monitoring; or (3) presumed 
treatment failure. Laboratories will use the LFA provided by the study to perform reflexive 
CrAg screening with study LFA on specimens from patients with CD4≤100 cells/μL or 
signs/symptoms of meningitis or among outpatient or hospitalized patients with WHO stage 3 
or 4 diseases at the discretion of the provider.  
Results of the CD4 and CrAg tests will be recorded daily by the participating laboratories, 
and results sent to the requesting OPC or hospital along with the CD4 count. All laboratories 
participating in Phase 2 will record the CD4 count, CrAg result, and indication for CrAg test 
along with the code for the requesting site and other data that are routinely included on the 
requisition form (typically age and birth year). Because Phase 2 is being implemented 
programmatically, laboratories will have the choice whether to incorporate the CRICS data 
(e.g., CrAg result and indication for CD4) in their routine laboratory logs or to use logs 
provided by CRICS. The data will be collected by the project team on a regular basis. 
Under Phase 2, participating CRICS laboratories are expected to inform the 
corresponding OPCs or inpatients wards, as well as the project team, of any CrAg-positive 
results as soon as possible. The patient’s primary providers are responsible for prescription of 
fluconazole and follow up according to their standard care procedures and national 

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guidelines. Fluconazole supply for identified CrAg-positive patients will be provided by the 
study if not readily available for the patient at the participating sites. We will monitor the 
prevalence of CrAg positivity through labs without enrolling patients into the study. 
7.2. Subject ID assignment (Phase 1) 
The assignment of participant ID will be only applied in the study sites. Each patient 
enrolled in the evaluation will be given a subject ID. This subject ID will be independent of 
the patient's OPC ID, which is assigned to each individual when they are registered at the 
OPC. The subject ID will take the following format :<XX>-<YYY> 
• XX: the letter code(s) assigned to each participating site using alphabetical letters. 
• YYY: the number which is assigned to an individual patient. This part has three 
characters from 001 to 999.  
Sequentially numbered subject IDs for each site will be printed and, after consent, 
assigned to each enrolled participant. A sticker with a pre-printed subject ID will be placed at 
the top of the first page of all case report forms (CRFs). Accurate records of assigned 
numbers will be kept and updated into Enrollment log at OPCs (see Appendix 14B: 
Enrollment Log for OPC) to ensure that no two patients are assigned the same subject ID. 
The study staff will be responsible for securing the patient’s information and minimize the 
risk of re-identification of the subject. 
In Phase 2, screened patients will be given a unique ID which is made of patient’s name 
in abbreviation, age, and OPC code. This would allow the study team to identify patients with 
duplication of CrAg results and track patients with positive CrAg results for their uptake of 
fluconazole. 
7.3. Management of a negative CrAg result 
a. Phase 1: Patients CD4 ≤100 cells/µL who have a negative plasma CrAg result will be 
managed in accordance with national guidelines which include the assessment for other OIs, 
adherence preparation, and starting ART. They will be followed up for a minimum of 6 
months and up to 12 months depending on the duration of the study period. Baseline data and 
follow-up data (2-.6-, and 12- month follow ups) will be collected on the enrollment and 
follow-up forms (see Appendix 4: Enrollment  and Appendix 6: Follow-up ). 
 

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b. Phase 2:Patients are not enrolled for follow-up. No clinical data will be collected apart 
from CD4 count, indication for CD4 test, and CrAg result. In addition, we will document 
number tested, number who are CrAg positive, and the respective CD4 counts.  
7.4. Management of a positive CrAg result 
a. Management of a CrAg-positive result - Phase 1 
Asymptomatic patients 
Patients with a positive CrAg test, and who consent to study participation will undergo 
routine examination at the OPC including assessment for presence of symptoms of meningitis 
(see Appendix). Patients who are plasma CrAg-positive but do not have symptoms of 
meningitis will be started on high-dose fluconazole as treatment for early cryptococcal 
infection.  
The optimal antifungal regimen in the population with isolated plasma CrAg remains to 
be determined.[11] The WHO Rapid Advice recommends that patients with isolated plasma 
CrAg-positivity should be treated with fluconazole 800 mg/day (or 12 mg/kg/day up to 800 
mg/day if aged below 19 years) for two weeks, then 400 mg/day (or 6 mg/kg/day up to 400-
800 mg/day if aged below 19 years) for eight weeks, and continued maintenance with 
fluconazole 200 mg/day is recommended [11]. In this program, maintenance fluconazole will 
be continued until CD4>200 cells/µL for at least 6 months.  
In Vietnam, the 150 mg tablet of fluconazole is the standard formulation and widely 
available for use in the national HIV treatment and care program for the treatment of CM. For 
this programmatic roll out, fluconazole dosage differs slightly from that recommended by the 
WHO recommendations but is in line with readily available formulations (150 mg tablets) in 
Vietnam, and with the updated national guidance [16]. The initial dosage of fluconazole in 
CrAg-positive patients therefore will be 900 mg taken each day for 2 weeks (WHO 
recommends 800mg). This will be followed by fluconazole 450 mg orally each day for 8 
weeks. Finally, maintenance treatment with fluconazole 200mg orally each day will continue 
until CD4 >200 cells/µL for at least 6 months. In accordance with the 2016 WHO guidelines, 
if HIV viral load monitoring is not available, fluconazole treatment will be continued until 
patient is stable and adherent to ART and antifungal maintenance therapy for at least one 
year. If HIV viral load monitoring is available, fluconazole treatment will be continued until 
patient is stable and adherent to ART and antifungal maintenance treatment for at least one 
year and has a suppressed viral load. Maintenance treatment after 6 months will be supported 
by VAAC with dosage of 150 mg per day as same dose as recommended by national 

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guideline for treatment of cryptococcal meningitis during maintenance therapy. VAAC is 
responsible for coordinating ART and OIs drug throughout the country, and they commit to 
support a full supply of fluconazole for patients enrolled in the screening program. Study 
findings will inform supply chain and other fluconazole logistical issues.  During treatment, 
development of adverse events (AEs) or side effects related to the use of this drug will be 
assessed during routine visits to each OPC and managed according to national protocols. 
 
LPs in asymptomatic patients 
In most study OPCs, asymptomatic, CrAg-positive patients will not be offered or referred 
for LP and CSF analysis since Vietnam National HIV Guidelines do not support the routine 
use of this invasive procedure in persons who do not have clear clinical features of a CNS 
infection [15]. Additionally, after discussions with multiple stakeholders at hospitals, 
conducting LPs on all asymptomatic CrAg-positive patients was felt to be unfeasible due to 
the limited availability of skilled clinicians and supplies for the procedure. However, patients 
who are CrAg-positive will be informed by the provider of the possibility of subclinical 
meningeal disease which can only be diagnosed by LP. If the treating doctors suggest LP to 
any patients who wish to pursue an LP outside of the program, they will be referred to an 
appropriate hospital. Study LFA may be used on serum or CSF as part of work up for patients 
with suspected meningitis. 
Patients who refuse fluconazole 
Patients who meet the indications for preemptive treatment with fluconazole but decline 
the treatment will have a one-on-one meeting with a designated clinic staff to ensure they 
understand the benefits of the antifungal therapy as well as the risks of not taking 
recommended treatment. If, after this meeting, patients still decline treatment with 
fluconazole, they will be strongly counseled about the need to return to the clinic for 
evaluation for symptoms consistent with cryptococcal disease. Patients will continue to be 
enrolled in the study and the collection of outcomes will continue. 
Symptomatic patients 
Plasma CrAg-positivity in a person with symptoms consistent with meningitis increases 
the suspicion for CM. If symptoms of meningitis (e.g., fever, headache, stiff neck) are 
determined by the treating physician to be present in a CrAg-positive patient, the patient will 
be referred to the nearest hospital capable of performing an LP and CSF analysis according to 
national protocols. Data from the hospitalization will be collected for analysis (Appendix 7: 

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Hospitalization ); however, evaluation and treatment of study participants with symptoms of 
meningitis will be determined by the treating physician in accordance with national 
guidelines. Patients with laboratory-confirmed CM will receive induction, consolidation, and 
maintenance phase therapy as per the Vietnam National HIV Guidelines. These might include 
intravenous amphotericin B 0.7-1mg/kg/day or high-dose fluconazole for two weeks 
(induction phase), followed by fluconazole 900 mg/day for 8 weeks (consolidation phase). At 
the end of the consolidation phase, fluconazole 200mg/day will be prescribed as secondary 
prophylaxis until CD4 >200 cells/µl for at least 6 months or after viral suppression. This is 
according to the national protocol and is not considered part of this evaluation [15, 16].  
Symptomatic CrAg-positive patients who refuse to have an LP or in whom an LP cannot 
be done will be offered the same treatment as laboratory-confirmed cases of CM, as outlined 
in the National Guidelines. If the patient refuses treatment for CM, they will be given oral 
fluconazole at the same dosage/length as asymptomatic CrAg-positive patients as a final 
option. 
Patients admitted for treatment of CM will remain in the study, and the study poin to 
contact (POC) at the OPC will be responsible for keeping in contact with the hospital to 
monitor the progress and document the patient’s outcome. The OPC staff will abstract 
information from the inpatient medical record and fill in the study Hospitalization Form (see 
Appendix) 
If, based on laboratory testing, the diagnosis of CM is excluded in patients suspected to 
have had meningitis (based on presence of fever, headache, or stiff neck) on initial 
evaluation, they will be treated by using the same protocol as asymptomatic CrAg-positive 
patients, i.e., started on fluconazole treatment for early cryptococcal disease (900 mg daily 
for 2 weeks) immediately after CM has been ruled out. This may be started during 
hospitalization (if patients remain hospitalized for other indications) or upon discharge from 
the hospital (if no other indication for hospitalization exists). All patients in whom CM is 
excluded should be provided with fluconazole upon discharge from the hospital so that 
treatment is not interrupted between hospital discharge and the next OPC appointment. After 
discharge, patients shall return to the OPC within two weeks to continue pre-emptive 
treatment as shown in Figure 1 below; 
 
b. Management of a CrAg-positive result- Phase 2 

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Under Phase 2, upon the receipt of CrAg positive test results from CRICS labs, the patient’s 
primary providers will be responsible for prescription of fluconazole and follow up according 
to their standard care procedures and national guidelines. Fluconazole will be donated to 
selected facilities for CrAg-positive patients if not otherwise readily available free of charge 
at the participating site.  
 
Patients will not be enrolled in longitudinal follow up. No clinical data will be collected apart 
from CD4 count, indication for CD4 test, and CrAg result, and in CrAg-positive patients, 
whether fluconazole treatment was initiated. In addition, we will document number tested, 
number who are CrAg positive, and the respective CD4 counts.  

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Figure 1: Management of Patients Enrolled in the CrAg Screening Program in Phase 1 
CD4 ≤100
Reflex crypto screen on 
remnant plasma
Enrolment in prospective cohort when a 
patient come for CD4 result (Baseline study 
assessment)
CrAg -
Regular care 
including 
assessment 
for OIs 
Initiation of 
ART, monthly 
evaluation
Follow-up for 
1 year
CrAg +
Assessment for other OIs, 
adminstration,  meningitis 
screening form
Meningitis 
screen  (+)
Evaluation determined by treating 
physician in accordance with 
national guidelines
LP Positive
freatment for CM determined by 
treating physician in accordance 
with national guidelines
Initiation of ART, 
scheduled evaluation
Follow-up for up to 1 
year
Cryptococcal meningitis 
not diagnosed
Start 
fluconazole
Initiation of ART, 
scheduled evaluation
Follow-up for up to 1 
year
Meningitis 
screen (-)
Start 
fluconazole
Initiation of ART, 
scheduled evaluation
Follow-up for up to 1 
year
Cryptococcal meningitis 
diagnosed 

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7.5. Fluconazole therapy 
Toxicity 
Fluconazole is a safe, widely used antifungal medication. The main side effects are nausea, 
headache, skin rash, abdominal pain, vomiting and diarrhea[18].In a study of high-dose 
fluconazole for HIV-associated CM in Uganda, fluconazole at both dosages of 800 mg/day and 
1200 mg/day appeared to be well tolerated. No patients discontinued fluconazole therapy 
because of suspected AEs before completing 14 days of treatment. Although fluconazole can 
cause liver dysfunction, in this study there was no statistically significant difference between the 
2 dosage groups in the percentage change in alanine aminotransferase (ALT) and serum glutamic 
pyruvic transaminase (SGPT) level [19]. 
Special populations 
Pregnancy: Fluconazole, a US Federal Drug Administration Category D medication, has 
been shown to be teratogenic in the first trimester of pregnancy. For this reason, it is 
contraindicated during the first trimester. Further, the effects of prolonged high-dose fluconazole 
later in pregnancy have not been confirmed.  
According to the Vietnam Guidelines for Diagnosis and Treatment [15]all ART-eligible 
female patients should have an initial assessment with obstetric, gynecological history and use of 
contraceptive methods documented. A urine pregnancy test is done based on need. For this 
study, a urine pregnancy test will be performed for all CrAg+ women of reproductive age (18–49 
years old) at the enrollment visit and during follow up in those where pregnancy is suspected 
(last normal menstrual period (LNMP) is > 5 weeks). Pregnancy is an exclusion criterion for 
study enrollment of CrAg+ women.  
Women who enroll in the study (Phase 1) will be given informed consent regarding the 
effects of fluconazole in pregnancy and its contraindication in pregnancy. During the consent 
process, they will be told that pregnancy testing will be required at enrollment and at any follow-
up visits if they have missed a period. They will be strongly encouraged to use a modern 
contraceptive method during the course of the study, and will be told to stop fluconazole 
immediately and to come to the clinic if they suspect pregnancy. 
At each study visit, for CrAg+ women of reproductive age, study staff will highlight the 
importance of not getting pregnant, the effect of fluconazole for pregnancy, and discuss 
contraceptive methods. Each of these women will be asked about her LNMP and her 

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contraceptive use. These data will be noted in the study records. If a female participant’s LNMP 
is > 5 weeks before the current visit, a urine pregnancy test will be performed to rule out 
pregnancy.  
Fluconazole will be discontinued immediately for women who become pregnant during the 
study period because of the drug’s teratogenicity during the first trimester. Pregnancy in these 
study participants will be considered a serious adverse event (SAE), reportable to the 
institutional review boards (IRBs) and funder. 
Other relevant contraindications: Patients with other relative contraindications will be 
advised accordingly. Patients with known liver disease, patients starting ART on anevirapine 
(NVP)-containing regimen, and patients on certain anti-tuberculosis (TB) medications will be 
given the following information and advised accordingly.  
• Patients with a history of liver disease: Patients with cirrhosis, hepatitis, jaundice, or 
abnormal liver enzyme tests (>2x upper limit of normal) will receive careful monitoring 
for signs of liver damage after beginning fluconazole treatment. These signs include right 
upper quadrant pain, nausea/vomiting, and jaundice. If signs of liver damage are present, 
liver function tests will be ordered and evaluated. 
• Patients starting ART: Patients on fluconazole starting ART will not be started on an 
NVP-containing regimen to avoid the synergistic hepatotoxicity of NVP and fluconazole 
treatment. For these patients, efavirenz (EFV) will be considered if there are no 
contraindications. 
• Patients with renal failure: Fluconazole is primarily renally excreted, thus dosing in 
patients with impaired kidney function needs to be adjusted based on the patient’s 
creatinine clearance. Discussion with a senior physician is recommended for patients who 
have impaired creatinine clearance to appropriately dose their fluconazole.  
• Patients with TB/HIV Co-infection: Because both fluconazole and TB medications can 
cause hepatotoxicity, patients co-infected with TB will be started on an EFV-based rather 
than an NVP-based ART regimen. Patients will be monitored closely for signs and 
symptoms of hepatotoxicity such as right upper quadrant abdominal pain, 
nausea/vomiting, or jaundice. If there are signs of toxicity, then liver function tests will 
be ordered and evaluated and managed as outlined in the sections below. 
Management of hepatotoxicity 

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Patients with hepatotoxicity will be managed according to the national guidelines[15]. 
• Management of hepatotoxicity when patients are on ART: 
 If ALT increases to grade 3 and the clinical status of the patients is stable, ART will be 
continued with less hepatotoxic drugs, such as EFV; with monitoring of ALT levels 
closely (every 2 weeks) and of the clinical symptoms; 
 HIV/HBV co-infected patients on 3TC, TDF will be monitored closely if they have to 
stop antiretroviral (ARV) drugs, for any reason. 
• Management of NVP Hepatotoxicity: 
Grade 
ALT 
Management 
Grade 1(Mild) 
1.25 - 2.50 times upper 
normal limit 
Continue with NVP. 
Monitor ALT closely in every 2 weeks 
Grade 2 
(Moderate) 
2.60 – 5 times upper normal 
limit 
Grade 3 
(Severe) 
5 - 10 times upper normal 
limit 
STOP NVP immediately. Continue with other 
2 drugs for 7 days, then replace NVP by EFV if 
ALT improves or  
If ALT is not improved, stop other 2 drugs. 
Restart ART only when ALT has improved; 
replace NVP with EFV-based regimen. 
Grade 4 
(Severe life-
threatening) 
> 10 times upper normal 
limit 
Take into account both ALT and clinical signs 
and symptoms for appropriate management. 
The ARV regimen can be stopped, patient 
hospitalized, or referred to higher level.  
Restart ART with NVP substituted with EFV or 
TDF or LPV/r on case-by-case basis 
 
7.6. ART 
Since 2011, the recommended first-line prioritized ART regimen in Vietnam includes 
tenofovir, lamivudine, andoneno-nucleoside reverse transcriptase inhibitor (NNRTI), either EFV 

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or NVP. This regimen is used for all ART initiators by national guideline unless there are 
contraindications to any of the drugs[20]. 
The optimal timing of ART initiation among patients with isolated CrAg-positivity (no 
evidence of CM) has not yet been established. In this program, initiation of ART will be delayed 
by 2 weeks in those who are Crag-positive to enable completion of 2 weeks of pre-emptive 
therapy with fluconazole. This delay is intended to prevent development of IRIS. The ART 
regimen selected will follow national guideline with a preference for EFV over NVP. CrAg-
negative patients will be evaluated at those clinics according to routine protocols and evaluated 
and initiated on ART, as appropriate.  
For patients with CM, the optimal timing of ART initiation has also not been established. 
However, 
the 
Cryptococcal 
Optimal 
ART 
Timing 
Study 
(ClinicalTrials.gov 
identifierNCT01075152), conducted in Uganda, aimed to evaluate early ART initiation after CM 
diagnoses (7-11 days after receipt of amphotericin B) versus late ART initiation (5 weeks after 
receipt of amphotericin B). This trial was stopped early after interim results from the study's 
Data Safety Monitoring Board review showed increased mortality among patients who were in 
the early ART initiation group[21]. Thus, in this program ART initiation will be deferred for at 
least 2-5 weeks after the start of antifungal treatment in order to comply with the best evidence 
to-date and national guidance [16].  
7.7. Schedule of visits – Phase 1 
Under Phase 1, all enrolled participants will attend routine scheduled visits at the OPCs. 
Evaluation procedures at each CRICS’s visit are indicated in the table and described in details in 
the sections below. There will be regular contacts by calls by OPC staff if a patient misses 
scheduled visits as a routine practice. 
(Note that under Phase 2, patients screened for CrAg are followed according to the routine 
OPC procedures, and no additional follow-up visits are conducted or data collected for CRICS 
apart from whether CrAg-positive patients receive fluconazole.)  
 
 
Visit 0 (V0) – Patients presenting for enrollment in HIV care during implementation period 

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Patient presenting for enrollment in HIV care at a participating clinic will be briefly informed 
about cryptococcal diseaseand CrAg screening on the remnant plasma from their CD4 count 
sample. (See 7.1. CrAg Screening Implementation (Reflex testing, return of results, 
communicating results and enrolment into the prospective cohort). For patients who have 
already had a CD4 test done in the2 weeks before the enrolment date, the remnant plasma from 
other routine tests ordered on the day of enrollment will be used for CrAg screening. If no other 
tests are requested on the day of enrollment, the patient will be asked to provide a fresh sample 
of blood for CrAg screening.  
 
Baseline Study Enrollment Visit– All Patients with CD4 ≤ 100 cells/µL 
On this visit, the patient will receive their CD4 count and plasma CrAg results. After having 
the study described to them and the opportunity to ask questions, patients will be asked to sign 
written, informed consent forms for participation in the study. A urine pregnancy test will be 
performed for women of childbearing age who are found to be CrAg-positive as described under 
special populations. A study ID will be assigned to those who have CD4 count ≤100cells/μL. A 
full physical examination will be performed and the Study Enrollment Form will be filled out 
(Appendix 4: Enrollment ). Patients who are CrAg-positive and have no evidence of meningitis 
will be prescribed and provided with fluconazole treatment for early cryptococcal disease. This 
will consist of 900mg per day for two weeks. Patients will be supplied with enough fluconazole 
to last until their next clinical visit (2 weeks). Patients who are CrAg-negative will follow 
standard clinic care.  
Patients who have symptoms suggestive of meningitis or other OI that requires 
hospitalization will be referred to hospital for evaluation as is routine practice in Vietnam. These 
patients will remain in the study and hospitalization data will be collected (Appendix 7: 
Hospitalization ) 
 
Follow-up Visits 
• CrAg-positive patients without symptoms of cryptococcal disease will be seen back at 
clinic after two weeks for evaluation and changing of their fluconazole dose to 450 mg 
per day (to be taken for 8 weeks) and initiation on ART as per the evaluation guidelines 
(see Appendix 5: Starting ART Form). They will subsequently return to clinic for an 

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evaluation eight weeks later, during which time a dose reduction in their fluconazole to 
200 mg per day maintenance dose will be completed.  
• Follow-up visits for fluconazole dose changes should occur 2 weeks after fluconazole 
initiation and then 8 weeks after. If these do not coincide with routine OPC appointment, 
then non-routine appointments should be made. Patients should be told the importance of 
coming back to the OPC at those designated times for fluconazole dose changes. CRICS 
evaluation will be conducted and follow-up data will be collected at these 2 types of 
follow-up visits. 
• CRICS evaluation and follow-up data collection should also be collected at routinely 
scheduled OPC visits that occur at ART initiation (if not at one of the above follow up 
visits), 2-, 6- and 12-months after ART initiation. Therefore, all enrolled CrAg-positive 
patients will be re-evaluated at 2-week and 10-weekafter fluconazole initiation and 2-, 6-, 
and 12-month follow-up after ART initiation (referred to as CRICS’s visit). The specific 
date of these CRICS’s visits might be decided in consideration of the patients’ regularly 
scheduled clinic visit. In these visits, a short follow-up form (see Appendix 6: Follow-up 
) which incorporates information on current symptoms, side effects of fluconazole (if 
they are on fluconazole) and other clinical outcomes should be filled out. 
• CrAg-negative patients will be re-evaluated at routinely scheduled visits for ART 
initiation and 2-. 6-, and 12-month follow-up visits. The follow-up data collection form 
should be filled for each of these visits.  
• All visits will be documented using Appendix 18: Patient’s visit logbook 
 
 

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Table 4. Schedule of select procedures and tests 
Procedure 
Pre-
Study 
V0  Baseline visit 
(Study 
enrollment) 
Follow-up visits 
HIV testing 
X 
 
 
 
CD4 testing* 
 
X 
 
X (6, 12 months) 
Viral load testing* 
 
 
 
After 6 and 12 months on ART (If 
available) 
Patient informed 
about availability of 
Crag screening  
 
Xa 
 
 
Patient provided with 
CrAg test result 
 
 
Xa 
 
Written consent 
 
 
Xa 
 
A urine pregnancy test  
 
Xa(for CrAg+ 
women) 
Xa (for CrAg+ women whose LNMP 
is more than 5 weeks prior) 
Enrollment Form 
 
 
Xa 
 
ART initiation form 
 
 
 
At the time of ART initiation as 
recommended by national guideline 
Health-related quality 
of life Form 
 
 
Xa 
At baseline, 6- and 12- month follow-
ups a 
Follow-up Form 
 
 
 
For CrAg-positive patients: 
At 2-weekb, 10 weekb, 2-a, 6-a and 12 
month a follow-ups 
For CrAg-negative patients: 
At 2-a, 6-a and 12 month a follow-ups 
Starting preemptive 
therapy of 
fluconazole-patient 
with CrAg (+) 
 
 
Xb 
 

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Reducing dose of 
fluconazole 
 
 
 
Xa (At the first day of 9th week) 
Off-study Form 
 
 
 
Xb (12 months after ART initiation) 
 
aStudy-related procedures, but conducted on patients’ routine visits for HIV care.  
bStudy-related procedures for CrAg-positive patients that may occur at a time separate from a 
routine OPC visit. 
*-MOH is in the process of implementing routine viral load monitoring. Results from CD4 and 
viral load test that are conducted routinely will be collected for CRICS.  
Minimizing loss to follow-up 
For patients who cannot be reached for a follow-up appointment or miss their follow-up 
appointment, a study-related red-coloured sticker will be placed on medical records to remind 
study staff at OPC of scheduled routine clinic visit or study visit. The note will be addressed to 
the nurse or physician and will be placed in the front of the file reminding them to inform the 
social worker or other assigned staff who routinely contact patients who miss appointments.  We 
will collect information about routine attempts to contact the patient and immediate outcomes of 
each attempt will be documented on a study form (see Appendix 8: Late Attendance, Missed 
Appointment ). 
Health-related quality of life (HRQOL) 
Since assessment of clinical outcomes (OIs, immune status CD4, survival rate) might not be 
reflect non-medical aspects of PLHIV, such as interpersonal, mental health and social functions, 
health-related quality of life will be used to measure the change in theses dimensions among 
participants. In this study, we employ EQ5D-5L (The EuroQoL-5 Dimensions-5 Levels) for 
measuring health-related quality of life of patients. This measurement provides a health profile 
and a single index value for health status, which includes five dimensions: Mobility, Self-care, 
Usual activities, Pain/Discomfort and Anxiety/Depression. EQ5D has been used among PLHIV 
in Vietnam, and shown to be valid for measuring HRQOL for PLHIV[22]. Moreover, EQ5D also 
provides a health utility score that is very useful for evaluating cost-effectiveness of the 
intervention. EQ5D will be assessed at the time of enrollment and every 6months (at 6- and 12-
month follow-ups) upon patient's choice. The HRQOL Form will be filled after follow-up form 

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(see Appendix). For patients who enrolled before HRQOL questionnaire was used, the EQ5D 
will be assessed only at 6- and 12-month follow-ups. 
 
8. Study Implementation 
8.1. Crag screening program launch meeting 
A meeting will be held to launch the screening project and to discuss implementation. The 
meeting will be attended by investigators, representatives from all sites, representatives from 
Centers for Disease Control and Prevention (CDC), other United States government agencies, 
other donors and implementing partners and will be chaired by VAAC. 
8.2 Pre-study training 
A training course is mandatory for the study implementation. It will be conducted before 
study implementation begins and after the launch meeting has been done. During implementation 
of the study, refresher training will be conducted in order to maintain competencies in the study 
protocol and address gaps in care and difficulties that arise in implementation.  
Clinician and laboratory staff training  
1. Before training, each participating OPC, laboratory, and hospital will be asked to select a 
POC person who will be in charge of coordinating the cryptococcal screening program at 
their site. Although others at each site may additionally be involved in training, the POC 
will be responsible for communication between their site and the other sites (OPC, lab, 
and hospital), and ensuring that data are collected appropriately and in a timely fashion. 
Additionally, a back-up POC will be identified at each site, in the event that the POC is 
away, leaves the facility, or cannot fulfill their duties. 
2. Training for both clinicians and laboratory staff will be carried out in parallel in Hanoi 
and Ho Chi Minh City by the investigators and subject matter experts from CDC-
Vietnam, CDC-Atlanta, and NHTD. Initial trainings will take place prior to the 
implementation of the cryptococcal screening program with planned refresher trainings 
as needed to account for personnel turnover and quality assurance.  
3. Clinician training will include outpatient-site training at the participating OPCs, and 

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inpatient-site training among referral hospital. Training will be conducted for each OPC 
and any relevant hospital staff. The following topics will be covered:  
a. Basic information about cryptococcal disease, including early and disseminated 
infection 
b. Explanation of the rationale behind the implementation of this screening program 
c. Review of the algorithm for implementation 
d. Role-playing using different clinical scenarios in order to ensure proper 
adherence to the algorithm and flow of patients.  
e. Good clinical practice 
4. Laboratory training will be inclusive of both outpatient participating laboratory staff 
serving the OPCs participating in the implementation of this screening program, and in-
hospital laboratory staff who will be performing CrAg LFA testing on CSF specimens at 
Tropical Diseases Hospital and National Hospital for Tropical Diseases. Training for 
laboratory staff will include: 
a. Instructions and practice in performing and interpreting the LFA CrAg test 
b. Review of the protocol for communicating CSF CrAg results to OPCs 
c. Reviewing the standard operating procedures (SOP) portions relevant to the 
laboratory staff.  
Training of all laboratory and clinical staff at all OPCs and laboratories will occur in a two-
week period preceding the program roll-out; in-country staff from NHTD, TDH, and CDC will 
return to the node laboratories, OPCs, and hospitals to provide refresher training as needed. The 
refresher training and training for new study staff will be performed on site as needed. 
8.3. Additional training in Phase 2 
Training for relevant staff from network laboratories, non-CRICS sites and affiliated 
inpatient wards will be conducted by the investigators and experts from CDC-Vietnam, CDC-
Atlanta, NHTD and TDH, and other local experts as relevant. The training contents will cover: 
 Screening procedures, roles and responsibility of each party in Phase 2 
 How to communicate CrAg results with OPCs and handle CrAg-positive results 
 Data collection  

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 Reporting requirements regarding the number of screened patients and CrAg+, as well as 
the any factors that affects the stability of CD4 testing (e.g. the availability of reagents, 
the functioning of CD4 count machines and any changes to the list of sites that the lab is 
conducting CD4 testing for) on a regular basis.  
8.4 Monitoring visits 
a. Phase 1 
Every 1-2months, the study coordinators/research associates/research assistant/data manager 
or other study staff will visit each of all study sites to supervise the study and collect data. Every 
six months, the regular visit will also includePrincipal Investigators or lead-coordinators and 
refresher training will be included as needed. The monitoring tasks include: 
• Checking that patients with CD4≤100 cells/µL have all been screened for CrAg 
• Checking the number of newly-enrolled patients 
• Checking if all patients enrolled since the last clinical research associate (CRA) visit have 
signed the informed consent forms. 
• Checking that fluconazole dosage of CrAg-positive patients is being changed according to 
protocol (section 7.4) 
• Checking that all CRFs are properly filled. 
• Checking the number of newly enrolled patients. 
• Recording all emerging issues during implementation, including ascertainment of changes to 
routine CD4 or viral load testing due to financing or other reasons. 
b. Phase 2 labs will be the focal point of contact in Phase 2 as all study activity related to CrAg 
screening and data collection will take place at labs. Thus, lab monitoring visits will be 
conducted on a monthly basis. The purpose of such monitoring visits is to:   
• The number of CD4 tests performed and number of tests having CD4 count ≤100 
cells/µL 
• The number of patients tested for CrAg and those with positive CrAg results 
• Obtain an updated lists of OPCs and sites that are served by the lab 
• The availability of reagents, the functioning of CD4 testing machines, and any factors that 
might influence the lab’s ability to perform CD4 testing 

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• Working closely with lab staff to ensure regular updating the expansion progress and timely 
data collection. 
8.5Management Meetings 
A meeting of the study management team will be held annually after implementation of the 
program. The meeting will involve the PIs and site investigators. Other meetings will include: 
• A quarterly teleconference with all investigators 
• A monthly meeting with the study investigators in Vietnam 
The topics will include: 
• Reporting the progress of implementation. 
• Reporting emerging issues during implementation. 
• Proposing solutions and recommendations for the remaining period. 
9. Specimen collection and processing 
9.1. Sample collection 
• Blood specimens will be collected from all patients at the time that routine CD4 count 
testing is being done. As mentioned above under visit 0, patients who have already had 
CD4 tests done in the2 weeks before the enrolment date, the remnant plasma from other 
routine tests ordered on the day of enrollment will be used for CrAg screening. If no 
other tests requested on the day of enrollment patients will be asked to provide a fresh 
sample of blood for CrAg screening.  
• CSF specimens will only be collected in patients with suspected meningitis on the basis 
of symptoms and who consent to LP. 
• Urine samples for pregnancy tests will be taken from CrAg+ women who are within the 
reproductive age group (under 55 years) at the enrollment visit and at follow-up visits for 
those whose last normal menstrual period began > 5 weeks prior.  
• Collection, transportation and storage of specimens will follow national CD4 testing 
guideline. 

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9.2. CD4 and CrAg LFA testing 
The CrAg LFA is a dipstick sandwich immunochromatographic assay. Specimens and 
specimen diluent are added into an appropriate reservoir, such as a test tube, and the lateral flow 
device is placed into the reservoir. The test uses specimen wicking to capture gold-conjugated, 
anti-CrAg monoclonal antibodies and gold-conjugated control antibodies deposited on the test 
membrane. If CrAg is present in the specimen, then it binds to the gold-conjugated, anti-CrAg 
antibodies. The gold-labeled antibody-antigen complex continues to wick up the membrane 
where it will interact with the test line, which has immobilized anti-CrAg monoclonal antibodies. 
The gold-labeled antibody-antigen complex forms a sandwich at the test line causing a visible 
line to form. Positive test results create two lines (test and control). Negative test results form 
only one line (control). If a control line fails to develop then the test is not valid. 
 
 
 
• Blood specimens for CD4 counts will be sent to the participating laboratory performing 
the CD4 count, with a request to test for cryptococcal antigen in those samples with CD4 
≤100 cells/µL. Remnant plasma from all specimens with CD4 ≤100 cells/µL will be 

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tested for CrAg. If the patients already had CD4 ≤100 cells/µL within the last 2 weeks, 
specimens of the remnant plasma from other routine tests or additional blood draws will 
be used. 
• In Vietnam, blood specimens for CD4 counts are kept in storage for quality control 
purposes as routine practice before being destroyed. For all patients who will undergo 
CrAg screening (those with CD4 ≤100 cells/µL), remnant plasma after of specimens with 
will be stored at -20°C until CD4 count result is returned to patients. The samples are 
only identified by a “serial laboratory number” and not names. We are referring to this as 
“temporary routine storage. Standard logbook of CD4 testing will be kept at the 
laboratory and individual results will be returned to the OPC as MO mandates. 
• When patients return to the clinic—usually within 2-3 weeks— to receive their CD4 
results, those with CD4 ≤100 cells/µL will be consented for “enrollment into the study”. 
Consent will also be sought for “storage of remnant plasma”. 
a. Patients who consent for study enrollment and for sample storage: Out Patient 
Clinic (OPC) Staff at participating sites will inform the lab about sample storage 
for patients who have consented. Their samples will be retrieved from “temporary 
routine storage”; a Study ID will be affixed and the laboratory number erased 
permanently. All samples will now be stored as “Study Samples in storage”. No 
other identifying information will be recorded and kept at the laboratory.    
b. The OPC will inform the lab periodically if patients do not come within the 
scheduled time usually 2-3 weeks. Their samples will subsequently be destroyed 
by the lab following the laboratory protocols for disposal of biological specimens. 
These samples will not bear a study ID. 
• The laboratory POC will contact the POC at the OPC by telephone each day with a list of 
patients and the results of CrAg testing. In addition, the laboratory will return the CrAg 
and CD4 test results as per their normal CD4 result notification process (e.g., paper 
laboratory reports delivered weekly).  
• Each laboratory will keep a facility list of all patients that were screened for plasma Crag 
from each participating OPC and the results of the CrAg test. A copy of this list will be 
retrieved by the OPC during the regular collection of CD4 results.  

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• Any unused plasma specimen for CD4 counts and leftover CSF will be stored frozen 
upon patients’ consent. All specimens will be securely stored at the NHTD for future 
testing for 10 years and will be destroyed by incineration after that. The specimens of 
participants who do not consent to long-term storage and additional testing will be 
discarded as using standard protocols. Approval for further testing will be sought prior to 
further testing from the relevant IRB. 
• The leftover specimen from non-enrolling patients will be destroyed after CrAg testing 
without storage. 
• Quality control: Participating laboratories will conduct internal quality control testing 
for the LFA reagents each day when samples are run or a new packet of kits is opened. 
CrAg-positive and negative control samples included in the kit will be tested to ensure 
the quality of the reagents and good testing practices. If the positive or negative controls 
do not yield the expected results, a new packet of LFA tests will be opened for use and 
the old packet discarded. If this does not result in appropriate positive and negative 
control results the matter will be reported to the study team for necessary corrective 
measures prior to further patient testing for CrAg. 
For CD4 count: Participating laboratories have participated in EQA program and 
performed IQC everyday of testing per national testing guideline to ensure quality of 
testing.   
9.3. LFA in CSF during evaluation of CM 
Clinical and laboratory training on the use and interpretation of the LFA in CSF will be 
conducted at participating hospital sites. For study participants who are referred to hospital for 
evaluation of meningitis, if an LP is done, the study will provide LFA for use in CSF in order to 
make a diagnosis of CM in study participants. Additional testing should be done per the 
hospital’s routine evaluation for CM. As LFA CrAg testing is not available routinely for the 
diagnosis of CM in Vietnam, guidance on interpreting the LFA in the context of other CM 
diagnostic test (e.g., India ink and culture) will be included in clinical and laboratory training 
(Table 5). 
 
Table 5: Guide to interpretation of CSF laboratory test results for the diagnosis of CM 

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LFA  
India Ink 
Culture 
Interpretation 
+ 
-/+ 
-/+ 
Positive for CM 
- 
+ 
-/+ 
Positive for CM 
- 
-/+ 
+ 
Positive for CM 
- 
- 
- 
Negative for CM 
 
9.4. Quality Assurance for LFA and CD4 count 
Training on quality assurance will be included into pre-study implementation training. 
Quality assurance site visits to the laboratory sites will be conducted by laboratory coordinators 
within one month after implementation starts, at least after one month, and then at least every 
three months to evaluate clinical and laboratory adherence to the SOP and laboratory technique. 
Laboratory quality assurance will be accomplished through: 
1. 
Direct onsite monitoring of assay performance by observing procedural accuracy, 
workflow, and appropriate biosafety practices and through employment of personal 
protective equipment and universal precautions during specimen handling. 
2. 
Proficiency testing (PT) via retesting of remnant specimens from consenting patients. 
Two remnant plasma or CSF specimens will be selected at each site, coded and retested 
using LFA and the results compared to initial test results as a measure of operator 
proficiency. If PT testing fails, refresher training will be provided.  
3. 
External quality assurance (EQA) tools, comprised of dehydrated CrAg antigen tubes 
(positive, low positive, and blank) will be prepared for all participating laboratories. 
During assurance visits, EQA tubes will be coded and rehydrated in physiological buffer, 
then tested with the CrAg LFA to ensure test kit quality, operator proficiency, and inter-
laboratory reproducibility. 
4. 
EQA program for CD4 testing will be performed routinely following national CD4 
testing guideline. 
Other measures of quality control that will be monitored and assessed during these visits 
include effective clinician-laboratory communication and potential protocol drifts. Corrective 
actions and follow-up will be implemented as needed to assure quality patient service. CDC-
Atlanta and CDC-Vietnam will assist with this basic program evaluation and provide input into 

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adjustments that will help improve process and flow of the CrAg LFA testing program 
implementation. A brief survey will be conducted among testers and personnel involved in the 
Quality Assurance program to evaluate. 
9.5. Measurement of CrAg titres 
The serial monitoring of CrAg may play a limited role in the management of HIV patients 
with CM[23]. In this study we will not be doing routine LPs on those who are Crag positive and 
serum CrAg titers will not be measured in real time but may be assessed on stored samples to 
evaluate correlation between the titers and clinical outcomes. 
 
10. Data Collection 
Phase 1 
Overview 
Demographic, clinical, treatment, and follow-up data will be obtained through chart 
abstraction into standardized CRFs. Data from CRFs will then be entered into Epi-Info (CDC, 
Atlanta). 
 
• At enrollment, eligible patients will have an ‘Enrollment Form’ (see Appendix 4: 
Enrollment Error! Reference source not found.) filled out by OPC clinic staff. Baseline 
patient variables included in this form are listed in the section “10.1. Patient variables.” 
Both CrAg-positive and –negative patients are also evaluated for quality of life (see 
Appendix 17: Health-related Quality of Life Form) on the day of their enrollment.  
• ART initiation form (Appendix 5: Starting ART Form): 
• A ‘Follow-up Form’ (Appendix 6: Follow-up Error! Reference source not found.) will 
be filled out for both CrAg-positive and –negative patients. All patients will be followed 
from enrollment for a minimum of 6 months and up to 12 months after ART initiation. 
The frequency of follow-up will be similar for both CrAg-positive and negative patients 
except for an additional visits to (i) reduce the dose of fluconazole to 450 mg and begin 
ART initiation 2 weeks after the baseline visit and (ii) for reduction of fluconazole to 200 
mg 8 weeks after the start of that dose (Refer to 7.4. Management of a positive CrAg 

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result). Specifically, for CrAg-positive patients, follow-up forms should be filled out at 2-
week after fluconazole, 10-week after fluconazole, 2-, 6-, and 12- month follow-ups after 
ART initiation. Whereas, for CrAg-negative patients, follow-up forms should only be 
filled out at 2-6-, and 12- month follow-ups after ART initiation. Follow-up patient 
variables are listed in the section “up. The history of appointment in all patients and 
history of fluconazole pre-emptive treatment among CrAg (+) patient will be recorded 
using AppendixandAppendix 19: Fluconazole preemptive treatment log respectively. 
• Patients’ quality of life will be re-evaluated at 6- and 12-month follow-ups after ART 
initiation.  
• If a patient requires hospitalization at any point during their 12-month follow-up period, 
data about hospitalization will be collected in a ‘Hospitalization Form’ (Appendix 7: 
Hospitalization Error! Reference source not found.). The clinical staff at the study site 
from which the patient is transferred will take charge of collecting these data after the 
patient has been discharged or died in the hospital (Appendix 11: Off Error! Reference 
source not found.). 
• An ‘Off-Study Form’ (Appendix 11: Off Error! Reference source not found.) will be 
used to collect data related to patient’s status, reason for study termination and to assess 
endpoints. 
• All follow-ups will be performed actively, to minimize patient loss to follow-up. Patients 
will receive a phone call one day before each scheduled visit to remind them of the 
appointment. These procedures are intended to minimize loss to follow-up and to 
ascertain patient status in those with a missed study visit at following enrolment into the 
screening program. 
In this amendment, a number of additional items are added to Enrolment Form, Follow-up 
Form and Off-study Form (health insurance, date of first registration with the OPCs, number of 
hospitalizations, and source of causes of death report). Such information will be collected 
prospectively on those who are enrolled after the approved amendment only. 
Phase 2 
For Phase 2: patients screened for CrAg will be managed by their providers according to the 
routine OPC procedures, and no additional study related follow-up visits will be conducted. No 

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additional data will be collected for CRICS, but the following data will be abstracted from the 
laboratory form or other log; CD4 count, indication for CD4 test (baseline or follow up), CrAg 
result, and for those who test CrAg-positive, whether fluconazole treatment was initiated) 
 
10.1. Patient variables 
a. Phase 1 
10.1.1. Individual variables – Baseline 
Sociodemographics 
• 
Gender 
• 
Date of birth (DOB) 
• 
Age (calculated field, if DOB is entered) 
• 
Marital status 
• 
Education level 
• 
Occupation 
• 
Monthly net income from all sources 
• 
Distance from home to clinic 
• 
Health insurance status 
Medical and past history 
• HIV-related (Date HIV testing/diagnosis, CD4 count, HIV Staging, OIs) 
• Past history (diabetes, hypertension, kidney failure, heart failure, stroke, chronic 
obstructive pulmonary disease  
Current symptoms:  
• Headache, seizures, night sweat, vomiting, nausea, abdominal pain, constipation, 
diarrhea, jaundice, cough, dyspnea, blurred vision, skin rash, fever, photophobia 
Performance status, Physical examination 
• Vital signs: Glasgow coma score, pulse rate, blood pressure, temperature, respiratory, 
weight, height 
• Chest examination, abdominal examination, neurological examination (neck stiffness, 
Kernig’ssign, cranial nerve palsies), visual examination, and fundoscopy 

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Laboratory tests 
• Hemoglobin 
• WBC, neutrophil %, lymphocyte % 
• Platelet count 
• Serum creatinine and serum urea 
• Serum aspartate transaminase (AST/SGOT) and alanine transaminase (ALT/SGPT) 
• Serum total bilirubin 
• Hepatitis B surface antigen (HBsAg), anti- hepatitis C virus (HCV) 
• Plasma CrAg test result 
• Pregnancy test result 
Initial management plan:  
Referral to hospital for LP 
• Initiation of fluconazole pre-emptive therapy 
• Dose of fluconazole, formulation of fluconazole 
10.1.2 Individual variables – Follow-up 
Missed visits: Number of visits patients are supposed to attend and the actual number of 
visits they made 
HIV Staging and OIs 
Current symptoms: headache, seizures, vomiting, constipation, skin rash, fever, 
photophobia 
Physical examination: Glasgow coma score, temperature, weight, neurologic examination, 
and skin exam, performance status 
Laboratory tests 
1. 
Hemoglobin 
2. 
WBC, neutrophil %, lymphocyte % 
3. 
Platelet 
4. 
Serum creatinine and serum urea 
5. 
AST/SGOT and ALT/SGPT 
ART 
1. 
Date of ART initiation 

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2. 
ARV drugs and dosage 
3. 
ART adherence: using self-report questions and visual analog scale 
Management plan:  
1. 
Referral to hospital for LP? 
2. 
Referral hospital 
Fluconazole pre-emptive therapy 
4. 
Current fluconazole dose 
5. 
Timing current symptoms to fluconazole AEs 
6. 
Fluconazole adherence: using self-report questions and visual analog scale 
 
c. Phase 2 
The following data will be abstracted from the laboratory form or patient record: CD4 test, CD4 
indication, CrAg result, and whether fluconazole treatment was initiated for patients who test 
CrAg-positive. Sex and birth year/age will be collected when available in the routine laboratory 
data (e.g., from lab requisition forms). 
 
10.2. Cost and cost-effectiveness analysis data 
Retrospective program cost data associated with CrAg screening, pre-emptive fluconazole 
treatment and CM treatment will be collected using standardized input type categories. A cost 
assessment will be done to assist policy makers to understand the costs per patient screened, cost 
per CrAg+ treated and cost per person treated for CM. Cost drivers in CrAg screening and 
CrAg+ treatment will also assessed across 22 OPCs, CRICS laboratories, and inpatient wards at 
CRICS-affiliated hospitals. The findings will assist policy makers in both understanding the 
benefits and resources necessary to implement CrAg screening and provide CrAg+ treatment. 
These data will be useful for advocating with the Government of Vietnam for inclusion of CrAg 
screening as part of a package for patients with advanced HIV in the list of services for HIV 
patients that are reimbursed by social health insurance. 
Data to be collected at all 22 OPCs, CRICS laboratories and inpatients wards at CRICS-
affiliated hospitals include: cost information, beneficiary volume, and site characteristics. We 
will collect data on costs from existing data systems or interviews with facility staff. We will use 

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a standard method ingredient-based cost analysis to derive the total cost and unit cost. We will 
retrospectively collect at a minimum 12-months of data from each OPC, CRICS labs and 
inpatient wards at CRICS affiliated hospitals. The timeframe may have to expand to capture 
costs associated with CrAg screening and CrAg+ treatment, but will be within the study 
enrollment period at each OPC. If patients were referred to other facilities for CM treatment, data 
collection for treatment costs will also be conducted at those facilities. Given the small number 
of CrAg positives who developed CM within the project so far, in order to achieve a better 
estimate of CM treatment costs, data will be also collected at inpatient wards in CRICS-affiliated 
hospitals. Cost data will be collected from the programmatic perspective, including all sources of 
financial or in-kind support to provide the services to allow an accurate assessment of resource 
needs. 
While all costs at the study site will be captured for analysis in this study, some resources 
will not be captured: 
• Indirect costs associated with HIV and CM-related morbidity and mortality, as well as 
those stemming from AEs associated with care and treatment. 
• Costs borne by the health system to increase the number of people who start and are 
retained on treatment. 
• Higher-level overhead costs borne by government agencies to support the intervention. 
• Out-of-pocket costs associated with care and treatment incurred by patients and their 
families. 
In addition, descriptive data will be collected at each study site to determine if any site 
characteristics may affect costs. These data include: 
• Site location  
• Maturity (duration of operations for CrAg screening and CrAg+ treatment) 
• Program model, encompassing aspects such as: 
- 
Staffing structure (e.g., nurses, doctors, administrative staff, etc.) 
- 
Capacity utilization 
- 
Comprehensiveness of other services provided at the study site 
The cost study will be led by a local health economist who will be supported by a CDC 
health economist on data collection instruments and economic evaluation method.  Data 
collection will be dictated by the data format and storage methods at the NHTD and at each site. 

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Data collection will be done by program activity and input type (Tables 5 and 6). As required, 
background calculations will be performed by the data collector to modify data into a 
standardized format so that they may be entered into the study instruments. Background 
calculations include but are not limited to: calculating annualized costs for capital investments 
and adjustments for mid-year salary changes. Data collection will be conducted by the local 
consultant and CRICS clinical research associates. Data entry will be performed at CRICS 
project office by data entry clerks or during fieldwork where appropriate. The data collection 
team will maintain control of hard copy and electronic versions of primary data, completed data 
collection forms, and undertake initial data cleaning and data quality control, in order to allow 
for rapid follow-up with site management and accounting staff for clarification where apparent 
errors, omissions or inconsistencies are found. Electronic data folders will be compiled for each 
site in preparation for analysis and will be integrated into the data collection for the rest of the 
CRICS project. These data will be used to develop a final data set that contains the final cleaned 
data. (Appendix 21: Cost study data collection tool).  
 
 
Table 6. Programmatic Activity Categories  
Training and Mentoring 
CrAg screening-specific training, mentoring and consultancies, continuing education of health 
care workers, personnel to perform CrAg screening. 
Clinical Care  
Provision of CM (diagnosed and non-diagnosed) care and treatment services. 
Lab Monitoring 
Provision of laboratory monitoring tests for CM negative and positive patients. 
Monitoring through the information and reporting system (if applicable) 
Entering monitoring results in the system of information.  
General Administration and Operations (if applicable) 
Management, administrative and maintenance activities at the facility. 
Table 7. Input Type Categories  

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Recurrent Costs 
Personnel 
The full cost of personnel employed for activities related to CrAg screening and CrAg+ 
diagnosis and treatment. This includes salaries or wages; employer share of taxes and fringe 
benefits; housing, transportation, and relocation support; signing and contract-fulfillment 
bonuses, and all other staffing expenses not captured in other categories. 
Travel 
The cost of transport, accommodation, per diems, and other incidental expenses of staff travel 
for activities related to CrAg screening and CrAg+ treatment. 
Drugs and Commodities 
The costs of medicines and other health commodities provided to patients as part of CrAg+ 
treatment services. 
LFA Test Kits 
The costs of LFA test kits provided to patients as part of CrAg screening services. 
Laboratory Supplies 
The costs of laboratory supplies expended as part of CrAg screening and CrAg+ treatment 
services.   
Other Supplies 
The costs of other supplies expended as part of CrAg screening and CrAg+ treatment services. 
Contracted Services (if applicable) 
The costs of activities contracted out to external service providers and not otherwise captured 
by other input type categories. 
Existing Buildings 
The cost of using existing buildings for providing CrAg screening and CrAg+ treatment 
services. 
Utilities 
The cost of utilities (power, water, electricity, etc.) expended for providing CrAg screening and 
CrAg+ treatment services. 
Investment Costs 

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In addition, cost data collected will be categorized by source of financial support (Table 8). 
 
The data on beneficiary volume will be collected through the CRICS project. The data will 
include de-identified aggregate data by study site on: 
 
• Number of patients screened for CrAg 
• Number of CrAg+ patients 
• Number of CrAg+ patients in treatment (classified by meningitis negative, meningitis 
positive, diagnosed CM and non-diagnosed CM) 
                                                 
 
2Training and Mentoring are considered as an input type as well as a programmatic activity in order to allow these 
costs to be clearly identified as investments. 
Training and Mentoring2 
CrAg and CM-specific training, mentoring, and continuing education of health care workers 
and other treatment facility personnel to support CrAg screening and CrAg+ treatment services. 
Laboratory Equipment 
The cost of laboratory equipment of significant value with a useful life exceeding one year 
acquired for use in providing CrAg screening and CrAg+ treatment services. 
Other Equipment 
The cost of other equipment of significant value with a useful life exceeding one year acquired 
for use in providing CrAg screening and CrAg+ treatment services. 
New Construction and Renovation (if applicable) 
The cost of new construction or renovation of buildings for use in CrAg screening and CrAg+ 
treatment services. 
 
Table 8. Source of Support Categories 
Vietnam Government 
Expenditures made by the Vietnamese government related to the CrAg screening and CrAg+ 
treatment services. 
United States. Government 
Funding provided by the United States government for project implementation. 

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In addition, we will use data from HRQOL collected in the CRICS project to estimate an 
incremental cost-effectiveness ratio.  
 
Data management and ownership for cost data will follow the standard of operations for other 
components of CRICS project. 
10.3. TmAg in Stored Samples (Sub-study) 
Talaromyces (formerly Penicillium) marneffei is a dimorphic fungus that causes a life-
threatening infection in immunocompromised individuals living and traveling in Southeast Asia, 
China, and India[24, 25]. Talaromycosis is a leading cause of AIDS-related deaths, trailing only 
TB and cryptococcosis, accounting for 4-15% of AIDS admissions in endemic regions[26-28]. 
Patients present very late in the course of illness, which has significant treatment morbidity and a 
mortality rate of up to 30%; treatment options remain limited[26-28]. The recent development of 
point-of-care cryptococcal LFA (such as CrAg®LFA) has allowed early diagnosis and 
prevention of CM by pre-emptive fluconazole therapy. The approach is shown to reduce HIV 
mortality[29], is cost effective in low- and middle-income countries[7, 10]and is in the treatment 
guidelines in 20 countries. 
Stored samples from the CRICS study provides the perfect opportunity to retrospectively 
investigate the prevalence and clinical significance of TmAg, as the patient population at risk for 
cryptococcosis is also at risk for talaromycosis. 
We will use a novel TmAg detection ELISA developed by the University of Hong Kong for 
screening[30]. The assay has been validated in the Oxford University Clinical Research Unit 
(OUCRU) laboratory in Vietnam in more than 600 HIV-infected patients with and without 
culture-confirmed talaromycosis. The ELISA has the sensitivity and specificity of above 90% 
and is more sensitive than blood culture in diagnosing talaromycosis (unpublished data). This 
assay was able to detect TmAg in 9.4% of more than 8,000 archived serum specimens from 
patients attending HIV clinics in Guangzhou, China[31]. Linked clinical data were not available 
in that study; therefore the clinical significance of TmAg could not be assessed. Mortality and 
other clinical outcome data from Phase 1 of the CRICS study will be used to assess clinical 
significance of antigenemia. 

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We hypothesize that the prevalence of TmAg in HIV-infected individuals with CD4 counts 
≤100 cells/µL will be at least 5%, and that asymptomatic TmAg is associated with a higher all 
cause morbidity and mortality.   
This study will provide further evidence for the MOH on the potential role of screening for 
TmAg (and pre-emptive itraconazole therapy for TmAg-positive patients), an approach that may 
substantially reduce the excess morbidity and mortality in patients starting ART in Tm endemic 
regions in Asia. 
Nearly all patients enrolled in CRICS agreed to the storage of blood specimens for later use; 
stored samples are identified only by study ID number.  All available specimens will be tested 
for TmAg by ELISA in the OUCRU laboratory in Vietnam. The assay requires 500 mcl plasma 
out of 500-1000 mcl stored samples.  
The study team will match the specimen’s ID with the patient’s ID as much as possible to 
ensure that positive TmAg results are returned to the primary doctors who are responsible for the 
clinical care for the patients. Secondly, doctors in OPCs with positive TmAg patients will be 
notified about the number of positive tests among their enrolled patients so as to increase their 
index of suspicion for T. marneffei infection. We hope that this will encourage providers to 
conduct intensive screening for symptoms of Talaromycosis during subsequent patient visits.  
Because TmAg is not the nationally approved laboratory test for diagnosis of T. marneffei 
infection in Vietnam, there is no official recommendation for treating asymptomatic patients who 
are TmAg positive. The decision on antifungal treatment will be made by the primary physicians 
based on local practice. The treatment regimen for those who are symptomatic will be 
determined by the primary physician on a case-by-case basis and will follow the standard of care 
at OPCs in accordance with national guidelines. Per the national guideline the treatment includes 
amphotericin B (0.7 -1,5 mg/kg/day) for 2 weeks, then itraconazole 200 mg bid (in children 5-6 
mg/kg bid) x 8- 10 weeks) or for mild cases or when Amphotericin B is unavailable, itraconazole 
200 mg bid x 8 weeks. Maintenance therapy includes itraconazole 200 mg/day in adults and 
Funding will be contributed by OUCRU to test specimens for TmAg. 
10.4.Datastorage 
CRFs will be used as a data collection tools. Source documents which are generated during 
the study by the clinical staff will be kept at the study sites. CRFs and other project documents 

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will be stored in a restricted-access room that only investigators and study staff can access. At 
NHTD, all project documents and copies of CRFs will also be protected in a secure room or 
locked cabinet; and personal data existing in non-digital format including CRFs or signed 
consent forms, containing names, addresses and signatures will be stored separately from data in 
a separated locked cabinet. After completion of the study, all study documents kept at study sites 
will be transferred back to NHTD. All essential documentation for all study patients will be 
maintained in original paper format by the investigators in a secured storage facility for a 
minimum of 3 years and as required by local regulations thereafter. All stored records will be 
kept secure and confidential. 
10.5. Data transfer 
Every 1-2 months, original completed CRFs from nearby study sites will be securely 
transported to NHTD for data entry and returned to the site afterwards for storage. CRFs from 
remote sites will be photocopied by the OPC POC and sent to NHTD for data entry. The original 
CRF will be maintained at the OPC. The copies of CRF or original CRFs will be secured in a 
locked box and protected by study staff during transferring.   
Following data entry, data will be stored in a personal computer (PC) secured with a 
password. A data entry officer will be responsible for data entry into the PC, using data entry 
software. The PC will have firewall protection and security-related upgrades and patches to 
operating systems to avoid viruses and malicious code. Only designated NHTD staff will be 
approved for access to the PC containing study data. It’s required to encrypt data containing 
personal information before they are stored. Confidential data such as those containing personal 
information will not be stored on servers or computers connected to an external network, 
particularly servers that host Internet services. Sending personal or confidential data via email or 
other file transfer means without encrypting is also not allowed.  
Besides, to reduce risk as far as possible, backups will be made after every change to data. 
There are at least two different forms of storage, for example on hard drive and on CD in case of 
accidental loss of data. Data files will be kept in portable computers, non-network computers and 
home-based computers. 

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10.6 Data ownership, governance, sharing, dissemination 
The database and samples arising from this study will remain the property of NHTD and 
investigators. NHTD also carries responsibilities to protect confidentiality and the privacy of 
research participants. Access to certain data sets will therefore be carefully managed and granted 
in a transparent manner to all appropriately qualified researchers. The final study database will 
be made available to and will be archived at NHTD. Investigators not affiliated with this study 
who are interested in analyzing the study data, will submit a brief proposal that will be reviewed 
by a study team that includes at least one study investigator from NHTD and one from CDC. 
In terms of TmAg sub-study, all TmAg-related data will reside at NHTD but will also be 
accessible all co-investigators from NHTD, CDC and OCRU. 
 
10.7 Data quality assurance 
Before sending to NHTD, the OPC POC will check the quality of all CRFs to ensure that all 
information has been properly collected and recorded. Data will be entered in an MS Access 
database. The MS Access sets up the tables before you can enter data and the data entry forms 
are incredibly flexible. There are different objects within the Access database file such as tables 
(which store the data), queries (which ask questions of the data), forms (used for data entry and 
editing) and reports (for summarizing data) – but there is just one single file (with the extension 
.mdb) so only one file to backup and/or pass to colleagues. Double data entry will be used to 
eliminate mistakes during data entry by checking for agreement with computer verification. The 
data manager at NHTD will provide feedback via phone calls and through coordinator’s visits to 
the study sites regarding any errors or missing data on a monthly basis, but forms are only 
transferred to NHTD every 2 months. During data processing, the information will be checked 
again for completeness and consistency. 
11. Data Analysis 
Data analysis plan:  
Primary objectives: 
Proportions will be calculated and presented with associated 95% confidence interval (CI). 
Clustering effect will be taken into account when calculating 95% CI. 

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Secondary objectives:  
Descriptive statistics (proportion, mean, standard deviations, median, and range) of all 
studied variables will be presented. Point estimates will be presented with associated 95% CIs. 
Chi square test will be used to compare proportions. T-test or ANOVA will be used to compare 
means. Logistic regression analysis will be used to examine factors associated with mortality.  
In addition, proportional hazards analysis will be used to study time to deaths and to compare 
survival between HIV-infected patients with CD4 ≤100 cells/µL enrolled in this study and who 
test CrAg+ and a historical cohort of patients enrolled in prior studies who were not screened for 
cryptococcal disease at the time of enrollment, but who test CrAg+ on stored specimens. 
Clustering effect will be taken into account in all analyses. Stata version 13.0 (Stata Corporation, 
College Station, TX) will be used for all statistical analyses. 
Cost and cost-effectiveness analysis 
The prices of some inputs may need adjustments for inflation if purchase occurred in earlier 
time periods, and all costs will be converted to a common currency, United States dollars (USD) 
for analysis (final results will be reported as both USD and Vietnam Dong). The cost data 
collection described in the previous sections allow the calculation of the total cost of the study 
intervention described by programmatic activity, input type, and source of funding. The analysis 
will evaluate the full and incremental costs of CrAg screening and CrAg+ treatment services.  
Donated or subsidized inputs are valued at their market value, and buildings are estimated as 
the amount of rent equivalent space in the local market. Likely shared costs are: buildings and 
lab equipment. Building costs would be shared based on an estimate of floor space. Lab 
equipment utilization data exist based on share of laboratory test runs by disease type. The cost 
analysis will be performed to evaluate the economic and financial costs. From the economic 
standpoint, the costs of capital investments (laboratory equipment and other equipment and 
civil/construction renovation) will be depreciated over the estimated cost of each item life, with a 
discount rate of 3%. Laboratory equipment will be assumed to have a lifetime of 7 years, while 
construction will have a lifetime of 20 years 
 
Clean and adjusted data on program costs will be analyzed to reveal: 
• Average cost per patient. 

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• Distribution of costs between the three categories described in Tables 5-7. 
• Differences in cost per patient between locations, OPCs and lab facility types and how 
this may or may not be explained by facility characteristic data. 
Specifically, programmatic activity costs will be aligned with patient data to calculate the 
following: 
• Cost per person screened and subsequently tested and treated. 
 
The incremental cost-effectiveness ratio (ICER) for each outcome (number of CM deaths 
averted and QALY) will also be calculated. The ICER adds value to the analysis by comparing 
the additional health benefit gained relative to the additional costs incurred when comparing the 
various interventions. The cost-effectiveness analysis is designed to answer the questions: “Is 
CrAg screening and associated CrAg+ treatment a cost-effective intervention to avert CM deaths 
and improve quality of life of HIV+ patients in Vietnam compared to SOC?” 
 
For example, the ICER of intervention A compared to intervention B is calculated as the 
difference in total costs between the two modalities divided by the difference in effectiveness: 
 
𝐼𝐶𝐸𝑅(𝐼𝑛𝑡𝑒𝑟𝑣𝑒𝑛𝑡𝑖𝑜𝑛 𝐴|𝐵) = 
(𝑇𝑜𝑡𝑎𝑙 𝐶𝑜𝑠𝑡 𝐴−𝑇𝑜𝑡𝑎𝑙 𝐶𝑜𝑠𝑡 𝐵)
(𝑇𝑜𝑡𝑎𝑙 𝐸𝑓𝑓𝑒𝑐𝑡𝑖𝑣𝑒𝑛𝑒𝑠𝑠 𝐴−𝑇𝑜𝑡𝑎𝑙 𝐸𝑓𝑓𝑒𝑐𝑡𝑖𝑣𝑒𝑛𝑒𝑠𝑠 𝐵) 
 
The ICER indicates the change in cost for one unit of outcome (i.e. the effectiveness 
measure) for different interventions. In this evaluation, the interpretation of the ICER will be the 
additional cost in dollars of CrAg screening and CrAg+ treatment compared to the SOC per CM 
death averted and QALY. The cost-effectiveness analysis will adopt the provider perspective.   
 
Sensitivity analysis will be performed on key parameters in the model to assess the 
robustness of the results to changes in base values of effectiveness measures or intervention 
costs.   
 
The cost data analysis, including the identification of cost drivers, sensitivity analysis or cost 
data, cost projection (financial resources requirements), and potential cost savings will be 
performed in STATA. The cost-effectiveness analysis will build on the exiting model developed 
by Smith et al.  

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12. Expanding implementation of CrAg screening: Feasibility 
To contribute to future roll-out of CrAg screening, lessons learned and challenges 
encountered during study implementation will be captured as they occur. Key aspects will 
include documentation of the following: 
• Training needs and materials for OPC staff 
• Laboratory infrastructure for CrAg screening and diagnosis of meningitis 
• Stability of CD4 testing during transition from international donor financing to 
Vietnamese sources and from CD4 monitoring to viral load monitoring 
• Sample transportation 
• Time for receipt of CrAg results 
 Patient referrals 
 Patient return for results 
• Patient flow 
• Patient acceptance of and adherence to fluconazole 
13. Ethical considerations 
13.1 Ethical review and informed consent 
The invitation to participate in this Cryptococcal Antigen Screening Program will be sent to 
all sites (see Appendix 13: Invitation to participate in the Cryptococcal Antigen Screening 
Program). Ethical approval for this program rollout and evaluation will be obtained from the 
NHTD Ethical Review board and from the CDC IRB. The protocol, consent forms and other 
study materials will be submitted. Final permission to conduct the study will be obtained from 
the MOH. 
 
Reflex CrAg screening on remnant plasma of all patients with CD4 ≤100 cells/µL: This 
testing is considered SOC as screening patients for plasma CrAg is included in the Vietnamese 
national guidelines and is also recommended by WHO[11]. 
 
• Informed consent for prospective cohort (Phase 1): Patients who return to the OPC for 
the CD4 result, will be explained and offered enrollment in the study if they meet 

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eligibility criteria (including CD4 ≤100cells/μL), regardless of CrAg result. The study 
staff will give the patient/legal representative a copy of the Informed Consent Form and 
explain the details of the study including the study procedures (including requirement for 
CrAg-positive women or reproductive age for pregnancy testing at enrollment and at any 
follow-up visits occurring >5 weeks after LNMP), risks and benefits, financial and 
confidentiality considerations, and how to obtain more information. The Consent Form 
will be in Vietnamese and will be translated and back-translated prior to study initiation 
to ensure the adequacy of the translation.  
• Study staff will invite the patient to ask questions and will endeavor to ensure that he/she 
understands the information given. The study staff will then ask the patient to consider 
study participation. The consent will cover 1) recruitment of eligible patients into the 
prospective cohort; 2) abstraction of relevant information from patients’ medical records 
at enrollment and during 12 months of follow-up; 3) permission to contact for reminder 
phone calls and tracking for those who miss routine appointments and 4) permission to 
store remnant specimen for future testing. 
Both CrAg-positive and negative patients will be enrolled for study participation. One 
Consent Form and Appendix 3B: Inform Consent Form (Vietnamese)) will be used for 
consenting CrAg-positive and negative patients. Patients who provide written informed consent 
to participate in the study will sign and date two copies of the informed consent form. The study 
staff will also sign and date the two copies. One copy will be given to the participant; the other 
will be retained and stored securely (see Confidentiality below) at the clinic. 
 If at any point in the consent process the patient is judged by the staff to be unable to give 
written informed consent because of altered mental state or unconsciousness, a relative or legal 
representative will approached and told about the study. If the patient/representative is illiterate, 
a witness who is not a member of the study staff will be present during the informed consent 
discussion. The Informed Consent Form will be read to the patient/representative in the presence 
of the witness. If the patient/representative agrees to participate, the form will be thumb printed 
by the patient/representative and signed and dated by the witness in case the patient is unable to 
sign.  
Those who refuse to give written informed consent will continue to be treated, as per the 
standard care at the clinic, but no data will be collected from them. 

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13.2. Waiver of consent (specific items) 
There are a number of routine procedures and quality improvement practices as a part of 
clinical care from which this study will draw aggregate, de-identified data. Regardless of CrAg 
screening results, supporting the adherence to therapy through the help of families, peer groups, 
healthcare workers are recommended by the MOH in accordance with decision No. 3003/QD-
BYT [15]. These items for which a waiver of consent is requested include: 
• A home visit from a health or a community worker and phone contact if a patient misses 
his/her appointment is a part of routine practice at study sites. This occurs for patients 
who have missed an appointment and also for patients lost to follow-up to encourage the 
patient to return for care and to determine whether the patient has transferred to another 
clinic, defaulted on treatment, or died. Initially, the patients are to be contacted by phone 
or, if that fails, a home visit is to be made. We believe that these routine procedures are 
beneficial to all patients at the sites, not only study participating patients. 
• Abstracting CD4 count and CrAg testing results in affiliated labs. The recommendation 
for CrAg screening was issued by the MOH in decision No. 3047/QD-BYT [16]. We 
believe that the routine monitoring of baseline CD4 to identify patients with advanced 
disease and of CrAg results will be beneficial to understand the prevalence of CrAg in 
select provinces and inform allocation of resources for differentiated care, including 
management of cryptococcal disease, for patients with advanced disease. 
 
13.3Confidentiality 
No names will be recorded on CRFs; CRFs will contain both study IDs and the client number 
from the OPC medical record. Data will be entered onto electronic databases on password-
protected computers, which will only be accessible to study personnel. Only study ID and not the 
participant’s OPC medical record number or name will be entered into the database. 
 

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13.4. Benefits/Risks 
13.4.1 Potential Benefits to Patients 
In 2011, WHO issued a conditional recommendation for routine screening for CrAg for 
PLHIV with CD4 ≤100 cells/µL in settings with a high prevalence of cryptococcal disease. Thus, 
the MOH aims to actively roll out routine CrAg screening in facilities providing HIV care. This 
evaluation will be implemented in the setting of program rollout. All patients with CD4 ≤100 
cells/will be screened for CrAg and managed by their providers. Patients enrolled in this study 
will receive routine care recommended by their providers including high-dose fluconazole for 
those who are CrAg-positive and lack a diagnosis of CM. The fluconazole will be provided by 
the study for the duration of the study; and for any patients requiring fluconazole after the 
completion of the study, fluconazole will be provided by the MOH.  
Although this study is being conducted in the setting of a program rollout under routine 
clinical conditions, enrolled participants may receive additional services such as reminder text 
messages and phone calls to ensure that they remain in care. This enhanced follow-up might 
reduce loss to follow-up and result in better care and outcomes for patients. If CrAg is detected, 
the patient will be treated with fluconazole, as recommended by WHO. The early detection 
opportunity can allow for earlier treatment of this infection, which is expected to improve the 
early mortality. 
The participating patients will be reimbursed 65,000 Vietnam Dong [approximately US$3] 
for the extra time spent at the facility for study-related activities, including the time which was 
used to for answer the QALY questionnaire. Payment will occur at the time of enrollment 
(baseline visit), 6, and 12 months. 
13.4.2 Potential benefits to the community  
This project aims to evaluate CrAg screening in Vietnam. WHO recommends that screening 
for cryptococcal antigenemia be considered in areas with a high prevalence of cryptococcal 
disease, among high-risk patients (adults with CD4 counts ≤100 cells/µL) [11]. Information from 
this study will help inform decisions about expansion of CrAg screening throughout Vietnam. 

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13.5. Potential Risks to Patients 
Risks from this program are minor. Plasma Crag-positive patients without CM will be 
receiving high-dose fluconazole as part of this study. Fluconazole, even at high doses (up to 
1200mg/day) is well tolerated and safe. Common side effects include stomach upset, headache, 
and rash. Serious side effects such as liver toxicity are rare, and patients will be monitored 
closely for any AEs related to fluconazole.  
13.6. Information dissemination 
Programmatic and implementation lessons for individual sites will be shared with individual 
sites and with VAAC for purposes of quality improvement. Overall findings will be presented to 
the Vietnam MOH and relevant implementing partners to inform policy. The results from this 
research will be presented at local, regional, and international conferences and published in open 
source journals to reach a wider audience in countries with limited resources. 
14. Safety monitoring and AE reporting 
This is an implementation science research project investigating the operational issues with 
implementation of CrAg screening and pre-emptive therapy. No experimental procedures or 
medicines will be used in this evaluation. A slightly higher fluconazole dose than that 
recommended by WHO will be used in this study. However, higher doses have been used in 
previous studies. We will monitor AEs and report any that are severe. Patients will not be 
monitored prospectively during Phase 2. If the study team happens to learn of any unexpected 
SAEs that are related or possibly related to CrAg screening in Phase 2, they will be reported to 
the IRBs. 
15. Sponsor Monitoring 
As the study sponsor, the CDC may conduct monitoring or auditing of study activities to 
ensure the scientific integrity of the study and to ensure the rights and protection of study 
participants.  Monitoring and auditing activities may be conducted by:  
• CDC staff (“internal”) 
• Authorized representatives of CDC (e.g., a contracted party considered to be “external”) 
• Both internal and external parties 

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Monitoring or auditing will be performed by means of on-site visits to the Investigator’s 
facilities or through other communications such as telephone calls or written correspondence. 
The visits will be scheduled at mutually agreeable times, and the frequency of visits will be at the 
discretion of CDC. During the visit, any study-related materials may be reviewed and the 
Investigator along with the study staff should be available for discussion of findings. 
The study may also be subject to inspection by regulatory authorities (national or foreign) as 
well as the independent ethics committees and IRBs to review compliance and regulatory 
requirements. 
AEs 
An AE is any undesirable event that occurs to a study participant during the course of the 
study; that is, from the time of signing the Consent Form until study end (i.e., until the last 
follow-up visit at 12 months) whether or not that event is considered related to fluconazole or 
ART.  
• Expected AEs: 
 Death due to CM 
 Symptoms of CM 
 Hospitalization for CM 
 Common ARV side effects 
 Death due to other OIs 
• Unexpected AEs: Serious unexpected AEs that will be reported including potentially life-
threatening reactions attributed to fluconazole and death (see Appendix 9: AE Reporting 
Form). 
 
Relatedness of AE to fluconazole 
Any AE that occurs will be assessed by the team physician to determine the relationship 
between the AE and the fluconazole. This relationship will be graded as follows: 
• Unrelated: clearly explained by another, documented cause 
• Unlikely related: more likely explained by a cause other than fluconazole 
• Possibly related: may be related to the drug or to another cause 
• Probably related: more likely related to the drug than to another cause 

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• Definitely related: direct association with fluconazole 
 
SAEs 
In this study, an AE is a SAE if it results in any of the following outcomes: 
• Death 
• Life-threatening event – this means that the participant was at immediate risk of death 
and required immediate medical intervention. It does not refer to an event which 
hypothetically might have caused death, if it were more severe. 
• Hospitalization, prolongation of existing hospitalization, or re-hospitalization once 
discharged. 
• Persistent or significant disability/incapacity (a substantial disruption of a person's ability 
to conduct normal life functions),  
• An important medical event that may not be immediately life-threatening or that result in 
death or hospitalization but may jeopardize the patient or may require intervention to 
prevent one of the other outcomes listed in the definition above.  
• Pregnancy in a CrAg-positive woman taking fluconazole 
• A congenital abnormality or spontaneous abortion 
 
Patient Management of AE 
Once an SAE is known, the research team should ensure that the participant receives or is 
referred for appropriate care. The participant should be treated by the treating physician and 
followed by the investigator until the abnormal parameter or symptom has resolved or stabilised. 
The physician should perform any tests that are clinically indicated as standard practice. The 
treating physician can stop fluconazole if he/she determines that a SAE is definitely related to 
this drug and is severe. If the SAE is judged to be possibly or probably related to oral 
fluconazole, the treating physician should consider and discuss with the PI the risks and benefits 
of continuing or stopping it. 
 
AE Recording  
Only certain AEs will be recorded on the CRF, including: 
• SAEs 

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• Unexpected AEs 
 
Reporting of AEs  
All SAEs and unexpected AEs must be reported to the study team within 2 working days. 
The study team will review all SAEs urgently to determine expectedness and relatedness. 
It is the responsibility of the Investigator to request all necessary documentation (e.g., medical 
records, discharge summary, autopsy) in order to provide comprehensive safety information and 
to assess whether the risks of study participation have changed.  
Those SAEs that meet all three criteria of Serious, Unexpected, and Related or Possibly 
Related must be reported to the study team as soon as the event is recognized; the initial 
report to the IRB will be generated by investigators within 2 working days of site-
awareness of the AE (see Appendix 9: AE Reporting Form and Appendix 10A: Clinical Study 
SAE Reporting ). The information on cases of death will also be captured in database using 
Appendix 10B: Clinical information for cause of death 
 
As above, patients will not be monitored prospectively during Phase 2. If the study team 
happens to learn of any unexpected SAEs that are related or possibly related to CrAg screening 
in Phase 2, they will be reported to the IRBs. 
 
16. Budget 
Will be submitted separately 
 

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17. Implementation schedule 
Table 9: Study timelines  
 
Months 
2014 
2015a 
2016 
~2017 
1-4 
5-9 
10-12 
1-4 
5-9 
10-12 
1-4 
5-9 
10-12 
1-4 
5-9 
10-12 
Phase 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol 
development 
 
 
 
 
 
 
 
 
 
 
 
 
IRB clearance 
(Atlanta/Vietnam) 
 
 
 
 
 
 
 
 
 
 
 
 
Preparation for 
data collection 
 
 
 
 
 
 
 
 
 
 
 
 
Hiring staff 
 
 
 
 
 
 
 
 
 
 
 
 
 
Training staff 
 
 
 
 
 
 
 
 
 
 
 
 
 
CrAg screening 
starts at all sites 
 
 
 
 
 
 
 
 
 
 
 
 
Phase 2 
 
 
 
 
 
 
 
 
 
 
 
 
TmAg screening 
 
 
 
 
 
 
 
 
 
 
 
 
 
Data 
Collection 
 
 
 
 
 
 
 
 
 
 
 
 
Data Analysis 
 
 
 
 
 
 
 
 
 
 
 
 
 
aRecruitment will continue for at least 18 months or whenever the minimum sample size is accrued

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References 
 
1. 
Park, B.J., et al., Estimation of the current global burden of cryptococcal meningitis 
among persons living with HIV/AIDS. AIDS, 2009. 23(4): p. 525-30. 
2. 
Bicanic, T., et al., Immune reconstitution inflammatory syndrome in HIV-associated 
cryptococcal meningitis: a prospective study. J Acquir Immune Defic Syndr, 2009. 51(2): 
p. 130-4. 
3. 
Shelburne, S.A., 3rd, et al., The role of immune reconstitution inflammatory syndrome in 
AIDS-related Cryptococcus neoformans disease in the era of highly active antiretroviral 
therapy. Clin Infect Dis, 2005. 40(7): p. 1049-52. 
4. 
Bamba, S., et al., Decreasing incidence of cryptococcal meningitis in West Africa in the 
era of highly active antiretroviral therapy. AIDS, 2012. 26(8): p. 1039-41. 
5. 
Lessells, R.J., et al., Poor long-term outcomes for cryptococcal meningitis in rural South 
Africa. S Afr Med J, 2011. 101(4): p. 251-2. 
6. 
Lawn, S.D., et al., Early mortality among adults accessing antiretroviral treatment 
programmes in sub-Saharan Africa. AIDS, 2008. 22(15): p. 1897-908. 
7. 
Meya, D.B., et al., Cost-effectiveness of serum cryptococcal antigen screening to prevent 
deaths among HIV-infected persons with a CD4+ cell count < or = 100 cells/microL who 
start HIV therapy in resource-limited settings. Clin Infect Dis, 2010. 51(4): p. 448-55. 
8. 
French, N., et al., Cryptococcal infection in a cohort of HIV-1-infected Ugandan adults. 
AIDS, 2002. 16(7): p. 1031-8. 
9. 
Micol, R., et al., Cost-effectiveness of primary prophylaxis of AIDS associated 
cryptococcosis in Cambodia. PLoS One, 2010. 5(11): p. e13856. 
10. 
Smith, R.M., et al., Prevalence of cryptococcal antigenemia and cost-effectiveness of a 
cryptococcal antigen screening program--Vietnam. PLoS One, 2013. 8(4): p. e62213. 
11. 
World Health Organization., Rapid advice : diagnosis, prevention and management of 
cryptococcal disease in HIV-infected adults, adolescents and children : December 
20112011, Geneva: World Health Organization. 44 p. 
12. 
Vietnam administration of HIV/AIDS control - MoH, Summary report of HIV/AIDS 
prevention in 2012 and plan for 2013. 04 /BC-AIDS, 2013. 
13. 
Lê Thanh Chiến and V.X. Huy. Causes of death in AIDS patients in Tropical Diseases 
Hospital [Vietnamese]. Available from: 
http://www.medinet.hochiminhcity.gov.vn/pcaids/TinTucDaoTao.aspx?Ma=40. 
14. 
Cuong do, D., et al., Survival and causes of death among HIV-infected patients starting 
antiretroviral therapy in north-eastern Vietnam. Scand J Infect Dis, 2012. 44(3): p. 201-
8. 
15. 
Ministry of Health, Guideline for diagnosis and treatment of HIV infection, 2009. 
16. 
Ministry of Health, Guidedance on management, care and treatment of HIV/AIDS, 2015. 
17. 
National Committee for AIDS- Drugs and Prostitution Prevention and Control, Viet Nam 
AIDS Response Progress Report 2012: Following up the 2011 Political Declaration on 
HIV and AIDS. 2012. 
18. 
Cousin, L., et al., Dosing guidelines for fluconazole in patients with renal failure. 
Nephrol Dial Transplant, 2003. 18(11): p. 2227-31. 

CRICS Study 
 
 
73 
Version 2.1 – Dated 7 January 2017 
 
19. 
Longley, N., et al., Dose response effect of high-dose fluconazole for HIV-associated 
cryptococcal meningitis in southwestern Uganda. Clin Infect Dis, 2008. 47(12): p. 1556-
61. 
20. 
Ministry of Health, Amendment to Decision 3003/QĐ-BYT of "Guideline for diagnosis 
and treatment of HIV infection" in Decision 3003/QĐ-BYT. 2011. 
21. 
David Boulware, D.M., C Muzoora, M Rolfes, K Huppler Hullsiek, A Musubire, K 
Taseera, H Nabeta, C Schutz, G Meintjes, and Cryptococcal Optimal ART Timing Trial, 
ART Initiation within the First 2 Weeks of Cryptococcal Meningitis Is Associated with 
Higher Mortality: A Multisite Randomized Trial, in 20th Conference on Retroviruses and 
Opportunistic Infections2013: Atlanta. 
22. 
Tran, B.X., A. Ohinmaa, and L.T. Nguyen, Quality of life profile and psychometric 
properties of the EQ-5D-5L in HIV/AIDS patients. Health Qual Life Outcomes, 2012. 10: 
p. 132. 
23. 
Powderly, W.G., et al., Measurement of cryptococcal antigen in serum and cerebrospinal 
fluid: value in the management of AIDS-associated cryptococcal meningitis. Clin Infect 
Dis, 1994. 18(5): p. 789-92. 
24. 
Vanittanakom, N., et al., Penicillium marneffei infection and recent advances in the 
epidemiology and molecular biology aspects. Clin Microbiol Rev, 2006. 19(1): p. 95-110. 
25. 
Supparatpinyo, K., et al., Disseminated Penicillium marneffei infection in southeast Asia. 
Lancet, 1994. 344(8915): p. 110-3. 
26. 
Le, T., et al., Epidemiology, seasonality, and predictors of outcome of AIDS-associated 
Penicillium marneffei infection in Ho Chi Minh City, Viet Nam. Clin Infect Dis, 2011. 
52(7): p. 945-52. 
27. 
Wu, T.C., et al., Clinical presentations and outcomes of Penicillium marneffei infections: 
a series from 1994 to 2004. Hong Kong Med J, 2008. 14(2): p. 103-9. 
28. 
Supparatpinyo, K., et al., Penicillium marneffei infection in patients infected with human 
immunodeficiency virus. Clin Infect Dis, 1992. 14(4): p. 871-4. 
29. 
Mfinanga, S., et al., Cryptococcal meningitis screening and community-based early 
adherence support in people with advanced HIV infection starting antiretroviral therapy 
in Tanzania and Zambia: an open-label, randomised controlled trial. Lancet, 2015. 
385(9983): p. 2173-82. 
30. 
Wang, Y.F., et al., Immunoassays based on Penicillium marneffei Mp1p derived from 
Pichia pastoris expression system for diagnosis of penicilliosis. PLoS One, 2011. 6(12): 
p. e28796. 
31. 
Wang, Y.F., et al., Serological surveillance for Penicillium marneffei infection in HIV-
infected patients during 2004-2011 in Guangzhou, China. Clin Microbiol Infect, 2015. 
21(5): p. 484-9. 
 
 
 
 
 
 
 
 

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List of Appendices 
Appendix 1: Screening Form 
Appendix 2A: Script informing patients of CrAg screening (English) 
Appendix 2B: Script informing patients of CrAg screening (Vietnamese) 
Appendix 3A: Inform Consent Form (English) 
Appendix 3B: Inform Consent Form (Vietnamese) 
Appendix 4: Enrollment Form 
Appendix 5: Starting ART Form 
Appendix 6: Follow-up Form 
Appendix 7: Hospitalization Form 
Appendix 8: Late Attendance, Missed Appointment Form 
Appendix 9: AE Reporting Form  
Appendix 10A: Clinical Study SAE Reporting Form 
Appendix 10B: Clinical information for cause of death 
Appendix 11: Off Study Form 
Appendix 12: Clinical scoring tools and WHO clinical stating of HIV AIDS 
Appendix 13: Invitation to participate in the Cryptococcal Antigen Screening 
Program 
Appendix 14A: Screening log for OPC (under Phase 1) 
Appendix 14B: Enrollment Log for OPC 
Appendix 15: CrAg Testing Request Form 
Appendix 16: CrAg testing log for the lab 
Appendix 17: Health-related Quality of Life Form 
Appendix 18: Patient’s visit logbook 
Appendix 19: Fluconazole preemptive treatment log 
Appendix 20: Script informing patients of reimbursement 
Appendix 21: Cost study data collection tool