title: Persistent high burden of invasive pneumococcal disease in South African HIV-infected adults in the era of an antiretroviral treatment program.
abstract: BACKGROUND
  Highly active antiretroviral treatment (HAART) programs have been associated with declines in the burden of invasive pneumococcal disease (IPD) in industrialized countries. The aim of this study was to evaluate trends in IPD hospitalizations in HIV-infected adults in Soweto, South Africa, associated with up-scaling of the HAART program from 2003 to 2008.
  
  
  METHODS
  Laboratory-confirmed IPD cases were identified from 2003 through 2008 through an existing surveillance program. The period 2003-04 was designated as the early-HAART era, 2005-06 as the intermediate-HAART era and 2007-08 as the established-HAART era. The incidence of IPD was compared between the early-HAART and established-HAART eras in HIV-infected and-uninfected individuals.
  
  
  RESULTS
  A total of 2,567 IPD cases among individuals older than 18 years were reported from 2003 through 2008. Overall incidence of IPD (per 100,000) did not change during the study period in HIV-infected adults (207.4 cases in the early-HAART and 214.0 cases in the established-HAART era; p = 0.55). IPD incidence, actually increased 1.16-fold (95% CI: 1.01; 1.62) in HIV-infected females between the early-and established-HAART eras (212.1 cases and 246.2 cases, respectively; p = 0.03). The incidence of IPD remained unchanged in HIV-uninfected adults across the three time periods.
  
  
  CONCLUSIONS
  Despite a stable prevalence of HIV and the increased roll-out of HAART for treatment of AIDS patients in our setting, the burden of IPD has not decreased among HIV-infected adults. The study indicates a need for ongoing monitoring of disease and HAART program effectiveness to reduce opportunistic infections in African adults with HIV/AIDS, as well as the need to consider alternate strategies including pneumococcal conjugate vaccine immunization for the prevention of IPD in HIV-infected adults.
authors.affiliation: Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases and Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Marta C
authors.initials: MC
authors.lastname: Nunes
authors.forename: Anne
authors.initials: A
authors.lastname: von Gottberg
authors.forename: Linda
authors.initials: L
authors.lastname: de Gouveia
authors.forename: Cheryl
authors.initials: C
authors.lastname: Cohen
authors.forename: Locadiah
authors.initials: L
authors.lastname: Kuwanda
authors.forename: Alan S
authors.initials: AS
authors.lastname: Karstaedt
authors.forename: Keith P
authors.initials: KP
authors.lastname: Klugman
authors.forename: Shabir A
authors.initials: SA
authors.lastname: Madhi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D023241:Antiretroviral Therapy, Highly Active; D017281:Cost of Illness; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011008:Pneumococcal Infections / Q000134:cerebrospinal fluid / Q000150:complications* / Q000151:congenital* / Q000453:epidemiology* / Q000401:mortality; D015203:Reproducibility of Results; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome; D055815:Young Adult