Advanced Human Immunodeficiency Virus Disease in Botswana Following Successful Antiretroviral Therapy Rollout: Incidence of and Temporal Trends in Cryptococcal Meningitis.
Tenforde, Mark W;
Mokomane, Margaret;
Leeme, Tshepo;
Patel, Raju KK;
Lekwape, Nametso;
Ramodimoosi, Chandapiwa;
Dube, Bonno;
Williams, Elizabeth A;
Mokobela, Kelebeletse O;
Tawanana, Ephraim;
+13 more...Pilatwe, Tlhagiso;
Hurt, William J;
Mitchell, Hannah;
Banda, Doreen L;
Stone, Hunter;
Molefi, Mooketsi;
Mokgacha, Kabelo;
Phillips, Heston;
Mullan, Paul C;
Steenhoff, Andrew P;
Mashalla, Yohana;
Mine, Madisa;
Jarvis, Joseph N;
(2017)
Advanced Human Immunodeficiency Virus Disease in Botswana Following Successful Antiretroviral Therapy Rollout: Incidence of and Temporal Trends in Cryptococcal Meningitis.
Clinical infectious diseases, 65 (5).
pp. 779-786.
ISSN 1058-4838
DOI: https://doi.org/10.1093/cid/cix430
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BACKGROUND: Botswana has a well-developed antiretroviral therapy (ART) program that serves as a regional model. With wide ART availability, the burden of advanced human immunodeficiency virus (HIV) and associated opportunistic infections would be expected to decline. We performed a nationwide surveillance study to determine the national incidence of cryptococcal meningitis (CM), and describe characteristics of cases during 2000-2014 and temporal trends at 2 national referral hospitals. METHODS: Cerebrospinal fluid data from all 37 laboratories performing meningitis diagnostics in Botswana were collected from the period 2000-2014 to identify cases of CM. Basic demographic and laboratory data were recorded. Complete national data from 2013-2014 were used to calculate national incidence using UNAIDS population estimates. Temporal trends in cases were derived from national referral centers in the period 2004-2014. RESULTS: A total of 5296 episodes of CM were observed in 4702 individuals; 60.6% were male, and median age was 36 years. Overall 2013-2014 incidence was 17.8 (95% confidence interval [CI], 16.6-19.2) cases per 100000 person-years. In the HIV-infected population, incidence was 96.8 (95% CI, 90.0-104.0) cases per 100000 person-years; male predominance was seen across CD4 strata. At national referral hospitals, cases decreased during 2007-2009 but stabilized during 2010-2014. CONCLUSIONS: Despite excellent ART coverage in Botswana, there is still a substantial burden of advanced HIV, with 2013-2014 incidence of CM comparable to pre-ART era rates in South Africa. Our findings suggest that a key population of individuals, often men, is developing advanced disease and associated opportunistic infections due to a failure to effectively engage in care, highlighting the need for differentiated care models.