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

2017; Oxford University Press; Volume: 65; Issue: 5 Linguagem: Inglês

10.1093/cid/cix430

1537-6591

Mark W. Tenforde, Margaret Mokomane, Tshepo Leeme, Raju K K Patel, Nametso Lekwape, Chandapiwa Ramodimoosi, Bonno Dube, Elizabeth A. Williams, Kelebeletse O. Mokobela, Ephraim Tawanana, Tlhagiso Pilatwe, William James Hurt, Hannah K Mitchell, Doreen L Banda, Hunter H. Stone, Mooketsi Molefi, Kabelo Mokgacha, Heston Phillips, Paul C. Mullan, Andrew P. Steenhoff, Yohana Mashalla, Madisa Mine, Joseph N Jarvis,

Viral-associated cancers and disorders

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.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.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.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.