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

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.

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