Advanced Human Immunodeficiency Virus Disease in Botswana Following Successful Antiretroviral Therapy Rollout: Incidence of and Temporal Trends in Cryptococcal Meningitis
CM in Botswana • CID
Advanced Human Immunodeficiency Virus Disease in Botswana Following Successful Antiretroviral Therapy Rollout: Incidence of and Temporal Trends in Cryptococcal Meningitis
Mark W. Tenforde 7 8
Margaret Mokomane 6
Tshepo Leeme 13
Raju K. K. Patel 12
Nametso Lekwape 13
Chandapiwa Ramodimoosi 6
Bonno Dube 11
Elizabeth A. Williams 10
Kelebeletse O. Mokobela 11
Ephraim Tawanana 15
Tlhagiso Pilatwe 14
William J. Hurt 13
Hannah Mitchell 13
Doreen L. Banda 13
Hunter Stone 9
Mooketsi Molefi 4
Kabelo Mokgacha 14
Heston Phillips 5
Paul C. Mullan 2
Andrew P. Steenhoff 3 13
Yohana Mashalla 4
Madisa Mine 6
Joseph N. Jarvis 0 1 4 13
0 Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania , Philadelphia , USA
1 Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine , United Kingdom
2 Children's National Health System , Washington, District of Columbia , USA
3 Division of Infectious Diseases, Children's Hospital of Philadelphia
4 University of Botswana
5 Joint United Nations Programme on HIV/AIDS , Botswana Country Office, Gaborone
6 Botswana National Health Laboratory
7 Department of Epidemiology, School of Public Health, University of Washington , Seattle , USA
8 Division of Allergy and Infectious Diseases, School of Medicine
9 University of Texas Southwestern Medical Center , Dallas , USA
10 St George's University , London , United Kingdom
11 Nyangabwe Referral Hospital , Francistown , Botswana
12 Imperial College London , United Kingdom
13 Botswana-UPenn Partnership , Gaborone
14 Botswana Ministry of Health , Gaborone
15 Princess Marina Hospital
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 100 000 person-years. In the HIV-infected population, incidence was 96.8 (95% CI, 90.0-104.0) cases per 100 000 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.
Botswana was the first country in Africa to establish a national
antiretroviral therapy (ART) program and began providing
treatment free of charge to its human immunodeficiency virus
(HIV)–infected population in early 2002 [
]. National HIV care
guidelines in 2012 recommended a CD4 T-cell threshold of
<350 cells/μL for ART initiation, up from <200 cells/μL in 2008
], and recent population-level data suggest that, in rural
regions, the program is close to achieving the “90-90-90”
targets set by the Joint United Nations Programme on HIV/AIDS
(UNAIDS) . Despite the success of the national ART
program, Botswana, a country of approximately 2 million people,
still has high incidence of new HIV infections in certain
populations and an HIV prevalence among the highest in the world,
with an estimated adult HIV prevalence of 25% in 2014 [
In sub-Saharan Africa as a whole, as in Botswana, although
millions now access life-saving ART, overall HIV prevalence is
still not declining and ART is initiated at low CD4 T-cell counts in
a majority of HIV-infected individuals [
], resulting in a large
population at substantial risk of opportunistic disease and with
high rates of mortality [
]. Care default and treatment failure
further increase the size of this high-risk population, with pooled
observational cohort data from African settings suggesting that
only 65% of patients starting first-line ART remain in care at
36 months, and virological failure and acquired ART resistance
are frequently observed [
]. Movement toward an HIV “test
and treat” strategy in sub-Saharan Africa, which was adopted in
Botswana in June 2016, will necessitate streamlining models of
care to quickly expand treatment programs, which has the
potential of leaving vulnerable patients further behind.
Cryptococcal meningitis (CM) is a severe fungal infection
primarily seen in individuals with defective cell-mediated
], with the vast majority of cases occurring in the
context of advanced HIV infection [
]. CM typically affects
individuals with CD4 T-cell counts <100 cells/µL, and is now
frequently described following late ART initiation and ART
default, as well as in ART-naive individuals [
]. As countries
move toward expanded HIV treatment programs, CM serves
as an important indicator disease for national programs. An
understanding of advanced HIV disease burden and temporal
trends in subpopulations will guide program delivery and
differentiated models of HIV care targeting groups most at risk for
delayed HIV diagnosis, ART initiation, and care default, with the
associated morbidity and mortality and high transmission risks.
We collected laboratory records from all facilities in Botswana
that perform meningitis diagnostics and UNAIDS country-level
HIV prevalence estimates to determine the 2013–2014 national
incidence rate of CM, describe characteristics of CM cases over
a 15-year period, and define temporal trends in cases diagnosed
at the 2 national referral hospitals.
The Botswana National Meningitis Survey was a 15-year
retrospective review of routine cerebrospinal fluid (CSF)
laboratory records to determine the etiologies of meningitis
in Botswana and temporal trends with maturation of the
local HIV epidemic. The study was conducted in
collaboration with the Botswana Ministry of Health and the National
Health Laboratory. Institutional review board (IRB) approval
was obtained from the University of Botswana, University
of Pennsylvania, University of Washington, Health Research
Development Council (Botswana Ministry of Health), and at
hospitals with independent IRB committees (Letsholathebe
Memorial Hospital, Mahalapye Hospital, Nyangabwe Referral
Hospital, Princess Marina Hospital, Scottish Livingstone
Hospital, and Sekgoma Memorial Hospital).
Participating Laboratories and Cerebrospinal Fluid Data Collection
Thirty-seven laboratories are registered by the Botswana
National Health Laboratory to perform CSF testing for the
diagnosis of CM by India ink stain, fungal culture, and/or
780 • CID 2017:65 (1 September) • Tenforde et al
cryptococcal antigen (CrAg) testing, including 2 national
referral hospitals, 7 district hospitals (6 medical, 1 psychiatric), and
28 primary, private, mining, and military hospital-based,
clinic-based, or stand-alone laboratories. Facilities were visited by
the study team for collection of meningitis-related laboratory
data. Most visits took place between February 2015 and May
2015. All available CSF records from 1 January 2000 through 1
January 2015 were located at facilities. Records were scanned on
a password-protected study laptop, then numbered and entered
into a REDCap database. To ensure data accuracy during
transcription of paper-based records into the REDCap database, a
minimum of 2 study team members reviewed each entry and
discrepancies were adjudicated through consensus.
In addition to paper records, a majority of hospital-based
laboratories maintain records on a government-financed electronic
medical record (EMR), the Integrated Patient Management
System (IPMS). At facilities with IPMS, clinical data are entered
directly into IPMS with laboratory books used to keep records
during Internet downtime or entered both in laboratory
notebooks and IPMS. IPMS was queried centrally at the Ministry of
Health to obtain all Botswana CSF-related electronic laboratory
records and HIV-related data (CD4 T-cell count nearest to the
date of CM diagnosis). Paper-based records from the REDCap
database were merged with IPMS records using Stata software
version 12 (StataCorp, College Station, Texas), matching by
date, testing location, and patient identifiers (name, age, sex),
with duplicate entries removed. Three hospitals used additional
EMR platforms for limited periods during the study period.
Electronic records from these EMR platforms were also queried
using CSF-related search terms, and these data were entered
into the REDCap database.
Population Denominator Data
The UNAIDS Spectrum model version 5.41 was used to
determine population numbers [
], national HIV prevalence, new
HIV infections, and the distribution of CD4 T-cell count. Two
module sets were activated for this projection. The
demographic set included DEMPROJ (to estimate the population by
age and sex) and FAMPLAN (to estimate the impact of family
planning services on population size). The HIV set included
AIM (to estimate the impact of HIV), GOALS (to estimate the
funding needed to achieve the national HIV response targets),
and RNM (to estimate the costs of implementing the national
HIV program). Model inputs were derived from published
country reports, strategic plans, costing studies, programmatic
data, and expert opinion [
Patients and Case Definition
Records were obtained of any patient who received a
lumbar puncture (LP) for CSF analysis without an age cutoff. In
Botswana, routine diagnostic CSF testing for CM includes
India ink stain and fungal culture. CSF testing for CrAg was
performed using latex agglutination tests by several centers and
routinely at referral hospital laboratories. The cryptococcal
lateral flow assay was not available in Botswana during the study
A “case” (or episode) of CM was defined as CSF with
positive India ink stain, Cryptococcus culture, and/or positive CSF
CrAg. As CSF analysis may have been repeated on patients
receiving multiple LPs for lowering of intracranial pressure or
other indications during an admission, all positive CSF samples
for a unique patient within a single documented hospitalization
(or in the absence of admission dates, within a ≤14-day window
of any previous CSF sample) were considered part of the same
Data were analyzed using Stata software version 12. Cases of
CM in Botswana were enumerated using the case definition.
The number of cases, recurrent cases, patient age and sex, and
month and season of diagnosis were described using
frequencies, percentage, or median and interquartile range (IQR), as
appropriate. It was not possible to calculate national incidence
rates over the full 15-year study period, as records prior to 2013
were partially complete. Complete CSF laboratory data from
all laboratories were obtained during 2013 and 2014 calendar
years. For these 2013–2014 national data, UNAIDS Spectrum
model HIV estimates were used as a population denominator
to determine the CM incidence rate in person-years of
observation (PYO) with 95% confidence intervals (CIs) derived using a
Poisson distribution. Incidence was estimated by sex and
ordinal age categories as well as by CD4 T-cell count category
stratified by sex in individuals ≥15 years of age.
The 2 national referral hospitals (Princess Marina Hospital
and Nyangabwe Referral Hospital) adopted IPMS in 2004
and also maintained paper-based records, yielding a complete
dataset for the 11-year period 2004–2014. At these 2 hospitals,
annual cases diagnosed over this 11-year period were displayed
graphically in relation to the “treatment gap”
(UNAIDSestimated HIV-infected population ≥15 years of age minus
population receiving ART) and median CD4 T-cell count at ART
15-Year Cryptococcal Meningitis Data
We identified 5296 unique cases of CM in 4702 individuals from
the period 2000–2014 (Table 1). Of these individuals, 90.3%
(4248/4702) experienced a single episode, 7.7% (360/4702) 2
episodes, 1.0% (48/4702) 3 episodes, and 1.0% (46/4702) 4 or
more episodes of disease. Median age at diagnosis was 36 (IQR,
30–43) years (Figure 1) and more cases were diagnosed in males
than females (60.6% males vs 39.4% females). There was no
evidence of seasonality. Case numbers did not differ with respect
to month or season at diagnosis.
Description of Cryptococcal Meningitis Cases in Botswana,
Total CM episodes
Total CM patients
Four or more episodes
Median and IQR
2013–2014 Incidence of Cryptococcal Meningitis
National incidence of diagnosed CM in 2013–2014 was 17.8
(95% CI, 16.6–19.2) cases/100 000 PYO, with higher incidence
observed in males than in females (22.0 [95% CI, 20.1–24.1]
cases/100 000 PYO in males vs 13.7 [95% CI, 12.1–15.3]
cases/100 000 PYO in females) (Table 2; Figure 2A and 2B). Peak
incidence was observed in 40- to 44-year-olds, with an earlier
peak among females (30–34 years) and a later peak among males
(40–44 years), mirroring national age trends in HIV prevalence.
In the HIV-infected population, overall incidence was 96.8
(95% CI, 90.0–104.0) cases/100 000 PYO, or 135.4 (95% CI,
123.4–148.3) cases/100 000 PYO in males and 66.3 (95% CI,
58.9–74.4) cases/100 000 PYO in females. Incidence rate was
relatively uniform across adult age categories, peaking in the
fourth through fifth decades of life (Figure 2C). Although the
absolute number of CM cases in children was relatively low,
incidence was comparatively high in the 2 youngest age
categories (0–4 years and 5–9 years), declining in the 10- to 14-year
age group, then increasing to adult levels in the adolescent
category (15–19 years). Note that the high incidence in the
0–4 years age category may be spuriously high due to an
underestimation of the denominator in the UNAIDS figures and low
overall numbers in both the numerator and denominator
categories. Incidence increased markedly with declining CD4 T-cell
count strata. In those with CD4 T-cell counts <50 cells/μL,
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.
a nearly 2% annual incidence was observed, of 1854 (95% CI,
1680.5–2042.0) cases/100 000 PYO, with higher incidence in
males than females across CD4 T-cell count strata (Figure 3).
Referral Hospital Temporal Trends
At the 2 national referral hospital laboratories, processing 60%
of CSF samples, the number of cases of CM cases decreased
between 2004 and 2014, with a marked decrease 2007–2009 but
only a modest decline in 2010–2014, despite a shift in national
ART guidelines recommending ART initiation at a higher CD4
T-cell count (<350 cells/μL in 2012 guidelines vs <200 cells/μL
in 2008 guidelines) [
]. Figure 4A shows cases of CM
diagnosed at the referral hospitals, with total HIV-infected
population in Botswana ≥15 years of age and population on ART over
time. Over this period, the median CD4 T-cell count at ART
initiation increased from 2007 to 2011 but remained stable
during 2012–2014 (Figure 4B), with similar trends observed in the
total population of HIV-infected individuals with CD4 T-cell
counts <200 cells/μL (Figure 4C).
These are the first robust national CM incidence estimates from
a resource-limited country. Collection of complete records from
all laboratories in Botswana performing CSF testing allowed
us to accurately estimate 2013–2014 national incidence rates,
revealing a high incidence of CM in Botswana in the context
of the highest population ART coverage in Africa. The 2013–
2014 Botswana national CM incidence is almost identical to the
pre-ART era (2002–2004) laboratory surveillance–based
incidence estimates from Gauteng Province, South Africa (17.8 vs
15.6 cases/100 000 PYO, respectively), a period when estimated
adult (15–49 years) HIV prevalence in South Africa was 21.5%
]. Limited to only HIV-infected populations, 2013–2014
Botswana incidence of 96.8 cases/100 000 PYO is again
comparable to South African incidence estimates from the pre-ART
era (95 cases/100 000 PYO), and >100-fold higher than the
2009 estimated United States HIV-associated CM rate of 7.7
cases/1 000 000 PYO .
The rate of decline in CM cases diagnosed at referral center
laboratories has stagnated in recent years, despite national
data showing high rates of HIV testing, ART uptake, and viral
]. These findings reflect a number of factors,
including high ongoing national HIV prevalence; only modest
improvements in median CD4 T-cell counts at ART initiation
in recent years, from 191 (IQR, 115–239) cells/μL in 2010 to
258 (IQR, 147–337) cells/μL in 2013 despite a shift in national
guidelines promoting earlier therapy [
]; and high annual
incidence of new HIV infection estimated at 1.5%–2.5% in
adults . Importantly, these findings suggest that, despite a
decade and a half of free and widely available HIV testing and
treatment services in Botswana, a population of vulnerable
individuals is not being effectively reached, engaged, or retained
by current testing and treatment services. This key population
is now the main driver of HIV-related morbidity and mortality,
and likely to be maintaining the high ongoing incidence of HIV
acquisition in this setting.
With stabilizing or rising adult HIV prevalence in Botswana
and the African region, eliminating the remaining treatment
gap and advanced HIV disease will require innovative
solutions to effectively reach key populations that are being missed
by current testing and treatment models, to diagnose and treat
early asymptomatic infection, and to promote lifelong
engagement with treatment services. Updated 2016 guidelines in
Botswana, in line with 2015 World Health Organization
guidelines, now recommend the “test and treat” strategy of ART at
any CD4 T-cell count for people living with HIV [
represents a critical step toward reducing advanced HIV
disease and opportunistic infections such as CM and
tuberculosis. However, the latest Botswana AIDS Indicator Survey data
estimated 30% of the population aged 10–64 years had never
undergone HIV testing in 2013 and ART coverage , at about
250 000 HIV-infected individuals by 2015 [
], needs to expand
by 100 000, which will put a strain on existing services [
Similar scale-up will likely be even more disruptive throughout
the rest of Africa, where the number of people receiving ART
needs to double to cover all HIV-infected individuals [
avoid leaving vulnerable individuals behind, differentiated care
models should be considered to streamline care for populations
with well-controlled disease and focus more intensive resources
on those with higher need, who are now driving the epidemic.
Our study provides important insights into the
characteristics of individuals presenting with advanced HIV and CM
in Botswana. We found peak incidence of disease in adults in
the fourth and fifth decades of life, suggesting a need to better
engage young, working-age adults through work- or
community-based care models that minimize lost opportunity costs.
Strikingly, we observed a >2-fold higher incidence of disease in
HIV-infected males than HIV-infected females. Although this
did not completely correct when the analysis was stratified by
CD4 T-cell count, perhaps in part reflecting a true sex-related
biological predisposition to cryptococcal disease for which the
pathogenesis is incompletely understood [
], it highlights
the high numbers of men presenting late to care or failing to
engage with testing and treatment services. Young women may
also have greater likelihood of HIV diagnosis and routine care
with prenatal, postnatal, and contraceptive services.
This study had several important limitations. First, these
estimates likely represent the lowest range of true CM incidence
rates in Botswana due to the limitations of deriving incidence
estimates from laboratory-based surveillance, including missing
individuals who died before seeking medical care or who sought
784 • CID 2017:65 (1 September) • Tenforde et al
care but went undiagnosed due to misdiagnosis, stockout of LP
equipment or laboratory reagents, or LP refusal [
we applied a rigorous approach to data collection and estimated
incidence only for 2013–2014 when we believed laboratory data
to be complete, missed case ascertainment may also have led to
spuriously low incidence estimates. A small number of
individuals may have sought care from neighboring countries, but this
is not likely to have significantly impacted our findings. More
than 85% of cases in the IPMS dataset had a Botswana national
identification number, and the vast majority of the remainder
could be identified as citizens using available identifying data.
Uncertainty in UNAIDS Spectrum model denominator
estimates could lead to either overestimation or underestimation,
although figures are based on the most robust and contemporary
data available and are validated against reliable national census
and HIV population prevalence survey results [
]. Second, as
a laboratory-based surveillance study, we did not have national
data on ART treatment history and were unable to stratify
incidence based on ART status. However, single-center data from
Princess Marina Hospital indicate that 51% of CM patients are
now presenting on ART [
], in keeping with other regional data
]. Third, we were unable to ascertain outcomes, although
2012–2014 data from Princess Marina Hospital showed a
10-week CM mortality of 50% and 1-year mortality of 65% .
The competing risk of high mortality could explain, in part, the
relatively low observed relapse rate. Finally, we were unable to
evaluate temporal trends in CM outside of the 2 referral
hospitals due to incomplete records, which might differ from urban
settings where referral centers are located. However, as almost
two-thirds of cases were diagnosed at referral centers, this
provides meaningful information regarding national trends.
In summary, we provide evidence for a high ongoing
burden of advanced HIV disease in Botswana, a country with a
mature ART program and the highest population ART
coverage in Africa. Our findings highlight a need not only to adopt
disease-specific measures to reduce CM, such as CrAg
screening in patients with advanced disease [
], but the broader
need to engage and link key populations to care who are being
missed with current strategies. Adoption of HIV “test and treat”
strategies could substantially reduce advanced HIV disease but
must be coupled with paradigm shifts in testing, care linkage,
and ART delivery such as differentiated care models and
decentralized testing and HIV care delivery.
Acknowledgments. We thank the Afya Bora Consortium; Diakanyo
Moalosi at the Botswana Ministry of Health for her assistance with querying
IPMS records; Freedom Ernest at the Botswana National Health Laboratory
for assistance with arranging laboratory visits; and multiple health
facility and laboratory personnel at Athlone Hospital, Bobonong Primary
Hospital, Deborah Retief Memorial Hospital, Ghanzi Primary Hospital,
GoodHope Primary Hospital, Gumare Primary Hospital, Gweta Primary
Hospital, Hukuntsi Primary Hospital, Kasane Primary Hospital, Lethlakane
Primary Hospital, Lobatse Mental Hospital, Mahalapye Hospital, Masunga
Primary Hospital, Letsholathebe Memorial Hospital, Mmadinare Primary
Hospital, Nyangabwe Referral Hospital, Palapye Primary Hospital, Princess
Marina Hospital, Rakops Primary Hospital, Scottish Livingstone Hospital,
Sefhare Primary Hospital, Selibe-Phikwe Hospital, Sekgoma Memorial
Hospital, Thamaga Primary Hospital, Tshabong Primary Hospital, Tutume
Primary Hospital, Extension 2 Clinic, Charles Hill Clinic, Area W Clinic,
Thebephatshwa Air Base, Bamalete Lutheran Hospital, Kanye Seventh-Day
Adventist Hospital, Jwaneng Mine Hospital, Diagnofirm Medical Center,
Gaborone Private Hospital Lancet Laboratory, Tati River Clinic Laboratory,
and Bokamoso Hospital Laboratory for their assistance. Individually, we
would like to thank Thato Mogapi, Bothwell Muviiwa, Kago Gofamodimo,
Olefile Bickie Bagwasi, Tlotlo Bogatsu, David Lubasi, Nobley Chunda,
H. Farrar Otieno, Felix C. Banda, Joy Mangilazi, Koabetswe Ramalepa,
Modisaotsile Emdee Ramaologa, Caroline Kekana, Stephen Motlhagodi,
Ephraim Dambe, Keoratile Ntshambiwa, George Simwanza, Phillip
Joseph, Cynthia M. Kuate, Steven Tsima, Jenny Tommy, Patrick Rancholo,
Finini Biyangidiki, Asini Mosango, Zein Sasikwa, Jacqueline Kasambala,
Keontse Nyamadzabo, Keteng Mphoyakgosi, Olivier Betu, Frank Nyimbili,
Moemedi Banda, Leabaneng Molomo, and Gabriel Malomo, among others
who provided assistance to our study team during laboratory visits.
Financial support. This work was supported by the Penn Center
for AIDS Research, a National Institutes of Health (NIH)–funded
program (grant number P30 AI 045008 to J. N. J.) as well as the NIH Office
of AIDS Research and Centers for Disease Control and Prevention/
President’s Emergency Plan for AIDS Relief grant support (grant number
U91HA06801B to M. W. T.). The REDCap platform is supported by grant
UL1TR000423 from National Center for Research Resources/NIH.
Potential conflicts of interest. J. N. J. has received funding support
from Gilead Sciences Europe. E. A. W. has received scholarship support
from Bristol-Myers Squibb Pharmaceuticals. All other authors report no
potential conflicts. All authors: No reported conflicts of interest. All authors
have submitted the ICMJE Form for Disclosure of Potential Conflicts of
Interest. Conflicts that the editors consider relevant to the content of the
manuscript have been disclosed.
CM in Botswana • CID 2017:65 (1 September) • 785
1. Farahani M , Vable A , Lebelonyane R , et al. Outcomes of the Botswana national HIV/AIDS treatment programme from 2002 to 2010: a longitudinal analysis . Lancet Glob Health 2014 ; 2 : e44 - 50 .
2. Botswana Ministry of Health. 2012 Botswana national HIV & AIDS treatment guidelines . Available at: https://hivpolicywatch.org/duremaps/data/guidelines/ BotswanaARTguidelines2012.pdf. Accessed 28 March 2017 .
3. Botswana Ministry of Health. Botswana national HIV/AIDS treatment guidelines: 2008 version . Available at: http://www.moh.gov.bw/Publications/HIVAIDS treatment guidelines. pdf. Accessed 28 March 2017 .
4. Gaolathe T , Wirth KE , Holme MP , et al; Botswana Combination Prevention Project Study Team. Botswana's progress toward achieving the 2020 UNAIDS 90-90-90 antiretroviral therapy and virological suppression goals: a population-based survey . Lancet HIV 2016 ; 3 : e221 - 30 .
5. Karim SA . Is the UNAIDS target sufficient for HIV control in Botswana? Lancet HIV 2016 ; 3 : e195 - 6 .
6. Joint United Nations Programme on HIV/AIDS (UNAIDS). HIV and AIDS estimates-Botswana . Available at: http://www.unaids.org/en/regionscountries/ countries/botswana/. Accessed 28 March 2017 .
7. Wang H , Wolock TM , Carter A , et al. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980 - 2015 : the Global Burden of Disease Study 2015. Lancet HIV 2016 ; 3 : e361 - 87 .
8. Siedner MJ , Ng CK , Bassett IV , Katz IT , Bangsberg DR , Tsai AC . Trends in CD4 count at presentation to care and treatment initiation in sub-Saharan Africa, 2002 - 2013 : a meta-analysis . Clin Infect Dis 2015 ; 60 : 1120 - 7 .
9. Avila D , Althoff KN , Mugglin C , et al. Immunodeficiency at the start of combination antiretroviral therapy in low-, middle-, and high-income countries . J Acquir Immune Defic Syndr 2014 ; 65 : e8 - 16 .
10. Brennan AT , Long L , Useem J , Garrison L , Fox MP . Mortality in the first 3 months on antiretroviral therapy among HIV-positive adults in low- and middle-income countries: a meta-analysis . J Acquir Immune Defic Syndr 2016 ; 73 : 1 - 10 .
11. Fox MP , Rosen S. Retention of adult patients on antiretroviral therapy in lowand middle-income countries: systematic review and meta-analysis 2008-2013 . J Acquir Immune Defic Syndr 2015 ; 69 : 98 - 108 .
12. Boender TS , Hoenderboom BM , Sigaloff KC , et al. Pretreatment HIV drug resistance increases regimen switches in sub-Saharan Africa . Clin Infect Dis 2015 ; 61 : 1749 - 58 .
13. TenoRes Study Group. Global epidemiology of drug resistance after failure of WHO recommended first-line regimens for adult HIV-1 infection: a multicentre retrospective cohort study . Lancet Infect Dis 2016 ; 16 : 565 - 75 .
14. Jarvis JN , Harrison TS . HIV-associated cryptococcal meningitis . AIDS 2007 ; 21 : 2119 - 29 .
15. Pyrgos V , Seitz AE , Steiner CA , Prevots DR , Williamson PR . Epidemiology of cryptococcal meningitis in the US: 1997 - 2009 . PLoS One 2013 ; 8 : e56269 .
16. Scriven JE , Lalloo DG , Meintjes G . Changing epidemiology of HIV-associated cryptococcosis in sub-Saharan Africa . Lancet Infect Dis 2016 ; 16 : 891 - 2 .
17. Rhein J , Morawski BM , Hullsiek KH , et al; ASTRO-CM Study Team . Efficacy of adjunctive sertraline for the treatment of HIV-associated cryptococcal meningitis: an open-label dose-ranging study . Lancet Infect Dis 2016 ; 16 : 809 - 18 .
18. Jarvis JN , Harrison TS . Forgotten but not gone: HIV-associated cryptococcal meningitis . Lancet Infect Dis 2016 ; 16 : 756 - 8 .
19. Avenir Health . Spectrum. Available at: http://www.avenirhealth.org/softwarespectrum.php. Accessed 28 March 2017 .
20. Avalos A , Phillips H , Jefferis K. Botswana investment case: investment towards effective HIV prevention, health system strengthening and the end of AIDS . Presented at: Botswana Ministry of Health. Gaborone, 2016 .
21. McCarthy KM , Morgan J , Wannemuehler KA , et al. Population-based surveillance for cryptococcosis in an antiretroviral-naive South African province with a high HIV seroprevalence . AIDS 2006 ; 20 : 2199 - 206 .
22. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2004 report on the global AIDS epidemic . Available at: http://files.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2004/GAR2004_en. pdf. Accessed 28 March 2017 .
23. Farahani M , Price N , El-Halabi S , et al. Trends and determinants of survival for over 200000 patients on antiretroviral treatment in the Botswana National Program: 2002 - 2013 . AIDS 2016 ; 30 : 477 - 85 .
24. Botswana Ministry of Health. Botswana AIDS impact survey IV 2013 . Available at: http://botswana.microdatahub.com/index.php/catalog/14. Accessed 28 March 2017 .
25. Botswana Ministry of Health. 2016 integrated HIV clinical care guidelines . Available at: http://www.moh.gov.bw/Publications/Handbook_HIV_ treatment_ guidelines . pdf. Accessed 28 March 2017 .
26. World Health Organization. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV . Available at: http://apps.who.int/iris/ bitstream/10665/186275/1/9789241509565_eng. pdf?ua=1. Accessed 28 March 2017 .
27. McGovern S , Phillips H , Mosime W , et al. Test results of testing cost-yield prioritization model for test and treat in Botswana . In: 21st International AIDS Conference, Durban, South Africa, 2016 .
28. World Health Organization. Global health sector response to HIV, 2000 - 2015 : Focus on innovations in Africa . Available at: http://apps.who.int/iris/bitstr eam/10665/198065/1/9789241509824_eng. pdf. Accessed 28 March 2017 .
29. McClelland EE , Hobbs LM , Rivera J , et al. The role of host gender in the pathogenesis of Cryptococcus neoformans infections . PLoS One 2013 ; 8 : e63632 .
30. Mitchell DH , Sorrell TC , Allworth AM , et al. Cryptococcal disease of the CNS in immunocompetent hosts: influence of cryptococcal variety on clinical manifestations and outcome . Clin Infect Dis 1995 ; 20 : 611 - 6 .
31. Thakur KT , Mateyo K , Hachaambwa L , et al. Lumbar puncture refusal in sub-Saharan Africa: a call for further understanding and intervention . Neurology 2015 ; 84 : 1988 - 90 .
32. Jarvis JN , Leeme T , Chofle AA , et al. High dose liposomal amphotericin for HIV-infected cryptococcal meningitis . In: Conference on Retroviruses and Opportunistic Infections (CROI) , Seattle, WA, 2017 .
33. Leeme TB , Patel RK , Azzo C , et al. Mortality due to HIV-associated cryptococcal meningitis in Botswana in the ART era . In: Conference on Retroviruses and Opportunistic Infections (CROI) , Seattle, WA, 2017 .
34. Meya D , Rajasingham R , Nalintya E , Tenforde M , Jarvis JN . Preventing cryptococcosis-shifting the paradigm in the era of highly active antiretroviral therapy . Curr Trop Med Rep 2015 ; 2 : 81 - 9 .
35. Mfinanga S , Chanda D , Kivuyo SL , et al. Cryptococcal meningitis screening and community-based early adherence support in people with advanced HIV infection starting antiretroviral therapy in Tanzania and Zambia: an open-label, randomised controlled trial . Lancet 2015 ; 385 : 2173 - 82 .
36. Lechiile K , Mitchell HK , Mulenga F , et al. Prevalence of advanced HIV disease and cryptococcal infection in Gaborone, Botswana . In: Conference on Retroviruses and Opportunistic Infections (CROI) , Seattle, WA, 2017 .
786 • CID 2017 : 65 ( 1 September) • Tenforde et al