TITLE: Prospective cohort of AIDS patients screened for cryptococcal antigenaemia, pre-emptively treated and followed in Midwest Brazil
AUTHORS: Moara Borges, João Alves de Araújo Filho, Marília Dalva Turchi

[DESCRIPTION]
<div class = "text-blocks"><div class = "text-block">This is a study carried out in partnership with of the Brazilian Cryptococcosis Network. It is the implementation of cryptococcal antigen (CRAG) screening and preemptive anti-fungal therapy of HIV-infected persons with advanced immunosuppression (CD4<200 cells/µl). </div><div class = "text-block">It aime to evaluate the prevalence of CrAg antigenemia, its associated factors and to measure outcomes of CrAg positive and negative subjects. </div><div class = "text-block">The participants will be recruited from June 2015 to July 2018 and followed through December 2019. Outpatients and inpatients assisted at the Tropical Diseases State Hospital “Dr. Anuar Auad”, in Goiânia, State of Goiás, Brazil, will have a serum CRAG performed by lateral flow assay. The population will be composed by adults, with HIV diagnosis, with a CD4 count ≤200 cells/µL, regardless of symptoms and with no history of cryptococcal disease. Lumbar puncture will be performed in every CrAg-positive individual to rule out cryptococcal disease.</div><div class = "text-block">Those who are CRAG-positive and have no CNS involvement will be treated pre-emptively with high dose fluconazole. Six months and 12 months after the end of recruitment period, the medical records will be reassessed for information of survival with retention-in-care in CRAG positive and CRAG negative and comparisons between groups.</div></div>

[STEPS]
?. Inclusion Criteria:Laboratory confirmed diagnosis of HIV-1 infectionCD4Age ≥18 yearsWith or without neurological symptomsHospitalized or outpatientRegardless of antiretroviral therapy (ARV) experience or adherence
?. Study Type: Prospective cohort
?. Exclusion Criteria:Prior known history of cryptococcal diseaseCurrent known pregnancy
?. RecruitmentThe recruitment of participants will be made by two strategies:1)Outpatient and in patients who fulfilled inclusion criteria and have no cryptococcal disease previously diagnosed, will be enrolled.  A medical appointment will be scheduled. The structured interview will be performed by the assistant physician or a medical researcher.
?. Recruitment2)The Central Laboratory of Public Health confidentially provide researchers with a list of patients with CD4
?. Structured InterviewDuring the scheduled visit or assistant physician evaluation, the main purpose of the study will be explained to the participant or legal reponsable. The risk of opportunistic diseases including cryptococcosis because of low cd4 count will be explained. The patients will be informed about the diagnostic test to be performed - serum CrAg using Lateral Flow Aassay (Immuno-Mycologics Inc®). The structured interview is based on an adapted form from the Brazilian Cryptococcosis Network. Socio-demographic, clinical and laboratory data will be accessed.Variables: age, sex, time of HIV diagnosis, CD4 cell count, HIV viral load, ART history, previous opportunistic infections and current systemic or neurological symptoms. General symptoms: fever, weight loss, asthenia, pulmonary symptoms, diarrhoea Neurological symptoms: headache, convulsions, changed mental state, dizziness, and visual or auditory deficit.
?. Management - CrAg negative The CrAg negative patients will be referred to the attending physician for follow-up and culture exams will be checked in the first 30 days.
?. Laboratory examsThe participantswill then referred to the hospital's internal laboratory for venipuncture and laboratory tests.- serum CrAg, fungal blood culture, blood count, proteinogram, urea, creatinine.- cerebrospinal fluid (CSF) rotine, fungal culture, India Ink, CrAg in CSFThe CrAg LFA test result will be available in up to 24 hours. The local laboratory will informe the researcher when the CrAg test was positive.
?. Management - CrAg positivePatients with positive antigenemia will be called up to an appointment with the researcher or the attending physician to rule out CNS involvement. A lumbar puncture will be performed with CSF  analysed. The risks of the procedure will  be clarified.CSF analysis: biochemistry, cellularity, India ink, direct research and culture for bacteria, fungi and mycobacteria and CrAg by LFA. When the rachimanometer is available, the intracranial pressure will be measured
?. Recruitment - Chart review Physical and electronic medical records will be accessed at the beginning of the study, objecting personal and laboratory background.
?. Management - CrAg positiveDuring couple months after the enrollment date, all positive subjects will be reassessed in at least 2 medical consultations with the researcher: for initial orientation and prescription of preemptive treatment (WHO Guideline 2018) and for assessing adherence. In the presence of cryptococcal meningitis, subjects receive treatment with amphotericin + fluconazole
?. ObjectivesEstimate the prevalence of cryptococcal antigenemia in an AIDS population from the Midwest of BrazilIdentify socio-demographic factors potentially associated with CrAg+;Identify clinical and laboratory aspects potentially associated with the CrAg+To evaluate the percentage of cryptococcal meningitis among patients with CrAg+To mesure outcomes of CrAg+ and CrAg- subjects
?. Outcomes - PrimaryRetention in care before/after CRAG screening implementation Adherence to ARTResistance to current ARVTime to undetectable viral load after recruitmentAdherence to treatment (pre-emptive fluconazole or amphotericin regime)
?. Outcomes - SecondarySurvival time among CRAG+ vs. CRAG negative persons with CD4<200 cells
Cryptococcal meningitis-free survival time in those who are CRAG positive and treated regularly or irregularly with fluconazole compared to CRAG-negative persons with CD4<200
Cryptococcal meningitis survival time
All-cause discontinuation of fluconazole
Opportunistic diseases during follow up
Cause of death
?. The follow-up will be maintained according to service routine.  Chart review (physical and electronic medical records) will access  outcomes at the end of recruitment period, in 6 and 12 months for follow-up evaluation.
?. Consent Form The interviewee will be informed that acceptance or refusal will not interfere with their regular follow-up at the service. After agreeing to participate, the written informed consent will be collected. The individuals allow the use of anonymous data for future scientific publications