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Background: HIV-associated cryptoccoccal meningitis (CM) causes hundreds of thousands of deaths annually in sub-Saharan Africa. Incidence should decline with greater access to ART, but this relies on early HIV recognition and linkage-to-care. We performed a laboratory-based surveillance study to determine the incidence of CM in Botswana, a country with a well-established ART program and high ARV coverage.
Methods: Data from all laboratories in Botswana performing cerebrospinal fluid (CSF) analysis were obtained for 2014 (paper registers and electronic records). Diagnosis of CM was confirmed by CSF microscopy/India ink stain, cryptoccoccal antigen (CrAg), and/or positive fungal culture. UNAIDS country-estimates for 2014 were used to calculate incidence of CM, stratified by age, gender, HIV-status and CD4 count. At the largest referral center in Botswana, Princess Marina Hospital (PMH), we evaluated temporal trends in CM diagnosis over a 15-year period (2000-2014).
Results: In 2014, 319 cases of CM were diagnosed in Botswana. Overall annual incidence was 15/100,000 persons (95%CI: 13-16/100,000). Incidence was 78/100,000 (95%CI: 68-87/100,000) in HIV-infected persons, and 249/100,000 (95%CI: 222-279/100,000) in adults (≥15 years) with AIDS (CD4 count < 200 cells/µL). 38% (121) of patients were female and the median age was 37 years (IQR 32-44 years) with only 3% (10/319) of cases in children (< 15 years). At PMH, there were 2047 cases of CM over 15 years, comprising 17.8% of all CSF samples in adults, making cryptoccoccal meningitis the most common laboratory-confirmed cause of meningitis (Figure).
Conclusions: A high burden of cryptoccoccal meningitis is still observed in Botswana, with no evidence of a reduction in case numbers over the past 6 years despite widespread ART access. Expanded HIV testing to prevent late presentation to care, CrAg screening in individuals with low CD4 counts, and HIV-program strengthening to prevent default from ART are required for prevention of cryptoccoccal meningitis and other opportunistic infections.

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