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BACKGROUND: Cryptococcal meningitis causes substantial mortality in high-HIV prevalence African countries despite advances in disease management and increasing antiretroviral therapy coverage. Reliable diagnosis of cryptococcal meningitis is cheap and more accessible than other indicators of AHD burden such as CD4 testing or investigation for disseminated tuberculosis; therefore, monitoring cryptococcal meningitis incidence has the potential to serve as a valuable metric of HIV programmatic success. METHODS: Botswana national meningitis surveillance data from 2015 to 2022 were obtained from electronic health records. All electronic laboratory records from cerebrospinal fluid samples analysed within government healthcare facilities in Botswana were extracted from a central online repository. Adjustments for missing data were made through triangulation with prospective cohort study datasets. Cryptococcal meningitis case frequency was enumerated using a case definition and incidence calculated using national census data. RESULTS: A total of 1,744 episodes of cryptococcal meningitis were identified; incidence declined from 15.0 (95% CI 13.4-16.7) cases/100,000 person-years in 2015 to 7.4 (95% CI 6.4-8.6) cases/100,000 person-years in 2022. However, the rate of decline slowed following the introduction of universal treatment in 2016. The highest incidence was observed in men and individuals aged 40-44. The proportion of cases diagnosed through cryptococcal antigen testing increased from 35.5% to 86.3%. CONCLUSION: Cryptococcal meningitis incidence has decreased in Botswana following expansion of ART coverage but persists at a stubbornly high incidence. Most cases are now diagnosed through the cheap and easy-to-use cryptococcal antigen test highlighting the potential of using cryptococcal meningitis as key metric of programme success in the Treat All era.
RESUMO
Introduction: Uninterrupted access to HIV and sexual and reproductive health (SRH) services is essential, particularly in high HIV prevalence settings, to prevent unintended pregnancy and vertical HIV transmission. Understanding the challenges that COVID-19 and associated social distancing measures (SDMs) posed on health service access is imperative for future planning. Methods: This cross-sectional study was conducted in Botswana between January-February 2021. A web-based questionnaire was disseminated on social media as part of the International Sexual Health and REproductive Health (I-SHARE) Survey. Respondents answered questions on SRH, before and during COVID-19 SDMs. Subgroup analysis and comparison of descriptive data was performed for people living with HIV (PLWH). Results: Of 409 participants, 65 were PLWH (80% female, 20% male). During SDMs, PLWH found it more difficult to access condoms and treatment for HIV and STIs; attend HIV appointments; and maintain adherence to antiretroviral therapy. Compared to HIV-negative women, a higher proportion of women living with HIV used condoms as their primary method of contraception (54% vs. 48%), and had lower use of long-acting reversible contraception (8% vs. 14%) and dual contraception (8% vs. 16%). Discussion: Mirroring global trends, COVID-19 disrupted HIV and SRH service access in Botswana. However, in high HIV-prevalence settings, disruption may more severely impact population health with disproportionate effects on women. Integration of HIV and SRH services could build health system capacity and resilience, reduce missed opportunities for delivering SRH services to PLWH and limit the consequences of future restrictions that may cause health system disruption.
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INTRODUCTION: UNAIDS has recommended that in 14 countries across sub-Saharan Africa (SSA), 90% of men aged 10 to 29 years should be circumcised by 2021 to help reduce transmission of HIV. To achieve this target demand creation programmes have been widely implemented to increase demand for Voluntary Medical Male Circumcision (VMMC). This review explores the effectiveness of demand creation interventions and factors affecting programme implementation. METHODS: We completed a mixed methods systematic review searching Medline, Embase, Global health, psycINFO and CINAHL databases in August 2018 with no time restrictions. Demand creation interventions conducted in SSA were categorized and quantitative data about VMMC uptake was used to compare relative and absolute effectiveness of interventions. Qualitative data were summarized into themes relevant to the delivery and impact of programmes. RESULTS AND DISCUSSION: Eighteen of the 904 titles were included in the review. Effective interventions were identified in each demand creation category: financial incentives, counselling or education, involvement of influencers and novel information delivery. Of the 11 randomized controlled trials (RCTs), the greatest absolute impact on VMMC prevalence was seen with a complex intervention including VMMC promotion training for religious leaders (compared to control: 23% (95% CI 22.8 to 23.8) absolute increase; odds ratio (OR) 3.2 (1.4 to 7.3)). Financial incentives generally produced the largest relative effects with men up to seven-times more likely to undergo VMMC in the intervention arm compared to control (adjusted OR 7.1 (95% CI 2.4 to 20.8), 7.1% (3.7 to 10.5) absolute increase). Qualitative findings suggest that interventions are more impactful when they are judged appropriate and acceptable by the target population; delivered by people with relevant personal experience; and addressing broader social and cultural influences through partnership with and education of community leaders. CONCLUSIONS: A range of demand creation interventions can increase VMMC uptake. The most acceptable and effective interventions are financial incentives framed as fair compensation (relative effect) and programmes of education or counselling delivered by people who are influential in the community (absolute effect). Future research should include larger studies with longer follow-up and a consistent definition of VMMC uptake.
