Cryptococcosis is now the most common cause of adult meningitis in much of Southern and East Africa [1]. Despite currently available antifungal therapies, acute mortality ranges from 30% to over 50% in published series [2, 3]. The result is that cryptococcal infection accounts for 10–20% of mortality in HIV-infected cohorts from sub-Saharan Africa [1], and recently published estimates by Park et al.[4] place the overall toll at an estimated 504 000 deaths in sub-Saharan Africa annually.

As part of an ongoing programme of work aimed at improving management of cryptococcal meningitis, we have prospectively monitored the number of new India ink positive cases of cryptococcal meningitis diagnosed at GF Jooste Hospital, Cape Town, South Africa, for the last 6 years (2003–2008). This is a public sector adult hospital serving a population of 1.3 million (including a large part of Khayelitsha township, population 500 000, with an HIV antenatal seroprevalence of 32.7% in 2006 [5]). During this period, the area served by the hospital and referral patterns for patients have not changed. Antiretroviral therapy (ART) access has been substantially increased in the public sector clinics in the hospital's referral area from 660 adult patients on ART at the end of 2003 to 13 985 by the end of 2008, based on figures from the provincial reporting system described elsewhere [6]. It is estimated that 60% of adults with new WHO stage IV HIV disease in this setting are now accessing ART [6]. But, despite this increase in the proportion of eligible patients receiving ART, the absolute number of patients with advanced disease not accessing treatment has remained constant or increased in recent years due to the evolution of the epidemic [6]. This is in keeping with our finding that there has been no reduction in the number of new India ink positive cases of cryptococcal meningitis presenting to our hospital over this period (Fig. 1).