An Enhanced Package of Care to Reduce Reduce Mortality in Advanced HIV Disease

A Community-based Phase III, Cluster Randomized Trial of Point-of-care CD4 Testing and Enhanced Screening and Prophylaxis in Advanced HIV Disease

A community-based Phase III, cluster randomized trial that seeks to determine the 24 week survival with retention in care of point of care CD4 testing with visitect and an enhanced package of screening and prophylaxis for opportunistic infections among patients with advanced HIV disease.

The study will be carried out in a population of HIV-infected adults with advanced HIV disease (CD4 <200 cells/µL) in Uganda. It will be a Randomized controlled trial, Phase III in Uganda over a duration of 5 years assessing 24 weeks survival with retention in care. @4 clinic will be randomized to either receive the enhanced package or standard of care.

Description of Intervention Arm

1. Point-of-care CD4 testing via Visitect (point of care semi Quantitaive CD4 LFA) lateral flow assay (LFA)

2. Enhanced package of opportunistic infection screening and prophylaxis for CD4<200, including:

   • FujiFilm SILVAMP TB LAM (FujiLAM)
   • Isoniazid (INH) + rifapentine: 1 month of therapy for latent TB(Tuberculosis) infection
   • Cryptococcal Antigen semi-quantitative (CrAg-SQ) LFA (Immy)
   • Treatment for disseminated CNS cryptococcal infection if high blood CrAg titer (>3+ CrAg SQ)

Description of Standard of Care Arm

1. CD4 testing by flow cytometry

2. WHO recommended package of OI screening and prophylaxis, including:

   • Urine TB LAM
   • INH ( isoniazid 6 months)
   • CrAg LFA
   • Fluconazole for asymptomatic CrAg+ o 800mg daily x 2 weeks, then 400mg daily x 8 weeks, then 200mg daily.

Problem statement: Current lab-based CD4 testing results in a delay to either start ART(Antiretroviral therapy) or a delay in screening persons with low CD4s for OIs. At present, prioritization has been on ART initiation without systematic OI screening. Those with subclinical OIs started on ART unmask their OIs, with hospitalization / deaths for OIs such as cryptococcosis and TB.

We hypothesize that with point of care CD4 testing, same-day OI screening can occur, yet not interrupt prompt ART initiation for those at low risk (FujiLAM and CrAg-SQ negative) of unmasking immune reconstitution syndrome.

We hypothesize that point-of-care CD4 testing will improve 6-month survival by reducing lag time in CD4 results, thereby facilitating ART initiation, retention-in-care, and OI screening and prophylaxis.

We hypothesize that enhanced screening with the point-of-care FujiLAM, CrAg-SQ LFA, with enhanced prophylaxis for TB (1 month of INH and rifapentine) and with treatment for disseminated CNS cryptococcal infection in those CrAg+ with high titers (>3+) will improve 6-month survival compared to current WHO-recommended standard practice in persons with advanced HIV disease.

Inclusion Criteria:

• Age >18 years
• CD4<200 cells/µL
• Ability and willingness to give informed consent for the enhanced package of care arm.

Exclusion Criteria:

• Known virologic suppression (viral load <1000 copies/mL) within prior 3 months
• Cannot or unlikely to attend regular clinic visits