Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, Washington, United States of America.
Department of Epidemiology, School of Public Health, University of Washington, Seattle.
Clin Infect Dis. 2017 Sep 1;65(5):779-786. doi: 10.1093/cid/cix430.
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.
博茨瓦纳拥有完善的抗逆转录病毒疗法（ART）计划，是该地区的典范。由于广泛提供 ART，预计晚期人类免疫缺陷病毒（HIV）和相关机会性感染的负担将会下降。我们进行了一项全国性监测研究，以确定 cryptococcal 脑膜炎（CM）的全国发病率，并描述 2000-2014 年期间病例的特征和 2 家国家转诊医院的时间趋势。
从 2000-2014 年期间，收集博茨瓦纳所有 37 家进行脑膜炎诊断的实验室的脑脊液数据，以确定 CM 病例。记录基本人口统计学和实验室数据。使用 UNAIDS 人口估计数，使用 2013-2014 年的完整全国数据计算全国发病率。从 2004-2014 年期间的国家转诊中心得出病例的时间趋势。
共观察到 4702 名个体中的 5296 例 CM 发作；60.6％为男性，中位年龄为 36 岁。总体而言，2013-2014 年的发病率为每 100000 人年 17.8（95％置信区间[CI]，16.6-19.2）例。在 HIV 感染者中，发病率为每 100000 人年 96.8（95％CI，90.0-104.0）例；在所有 CD4 层均可见男性优势。在国家转诊医院，2007-2009 年期间病例减少，但 2010-2014 年期间稳定。
尽管博茨瓦纳的 ART 覆盖率很高，但晚期 HIV 的负担仍然很大，2013-2014 年的 CM 发病率与南非的 ART 前时期相当。我们的研究结果表明，由于未能有效参与护理，很大一部分人群（通常为男性）正在发展晚期疾病和相关机会性感染，这突显了需要采用差异化的护理模式。
