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. 2017 Sep 1;65(5):779-786.
doi: 10.1093/cid/cix430.

Advanced Human Immunodeficiency Virus Disease in Botswana Following Successful Antiretroviral Therapy Rollout: Incidence of and Temporal Trends in Cryptococcal Meningitis

Mark W Tenforde  1   2 , Margaret Mokomane  3 , Tshepo Leeme  4 , Raju K K Patel  5 , Nametso Lekwape  4 , Chandapiwa Ramodimoosi  3 , Bonno Dube  6 , Elizabeth A Williams  7 , Kelebeletse O Mokobela  6 , Ephraim Tawanana  8 , Tlhagiso Pilatwe  9 , William J Hurt  4 , Hannah Mitchell  4 , Doreen L Banda  4 , Hunter Stone  10 , Mooketsi Molefi  11 , Kabelo Mokgacha  9 , Heston Phillips  12 , Paul C Mullan  13 , Andrew P Steenhoff  4   14 , Yohana Mashalla  11 , Madisa Mine  3 , Joseph N Jarvis  4   11   15   16
Affiliations

Advanced Human Immunodeficiency Virus Disease in Botswana Following Successful Antiretroviral Therapy Rollout: Incidence of and Temporal Trends in Cryptococcal Meningitis

Mark W Tenforde et al. Clin Infect Dis. .

Abstract

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.

Keywords: Botswana; HIV; cryptococcal meningitis; incidence; sub-Saharan Africa.

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Figures

Figure 1.
Figure 1.
Age distribution of cryptococcal meningitis cases in Botswana, 2000–2014.
Figure 2.
Figure 2.
Incidence of cryptococcal meningitis in Botswana by age category, 2013–2014. A, Overall incidence and interquartile range. B, Incidence by sex (males, solid bars; females, striped bars). C, Incidence in human immunodeficiency virus–infected population. Abbreviation: PYO, person-years of observation.
Figure 3.
Figure 3.
Incidence of cryptococcal meningitis in Botswana in human immunodeficiency virus–infected population by CD4 strata, 2013–2014. A, Overall incidence. B, Incidence by sex (males, black lines; females, gray lines). Abbreviation: PYO, person-years of observation.
Figure 4.
Figure 4.
Trends in diagnosed cases of cryptococcal meningitis (CM) at the 2 national referral hospitals in Botswana, 2004–2014. A, Cases diagnosed at referral hospitals (thick black line) and treatment gap in adults (≥15 years of age) (shaded gray area). B, Joint United Nations Programme on HIV/AIDS (UNAIDS) estimate of median CD4 T-cell count at antiretroviral therapy initiation in Botswana. C, UNAIDS estimate of total number of human immunodeficiency virus–infected individuals with CD4 T-cell counts <200 cells/μL.
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References

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