Global trends in CD4 cell count at the start of antiretroviral therapy: Collaborative Study of Treatment Programs. Clinical Infectious Disease
Anderegg et al. on behalf of IeDEA and COHERE examined global trends in CD4 cell counts at combination antiretroviral therapy (cART) initiation among adults from low-income (LICs), lower-middle-income (LMICs), upper-middle-income (UMICs), and high-income (HICs) countries.
A total of 951’855 adults were included. Overall, the modeled median CD4 cell count at the start of cART increased from 2002 to 2015,
from 78/μL to 287/μL in LICs,
from 99/μL to 234/μL in LMICs,
from 71/μL to 311/μL in UMICs, and
from 161/μL to 327/μL in HICs.
In LICs, LMICs, and UMICs, the increase was more pronounced in women; in HICs, the opposite was observed. There were important differences between regions: the estimated median CD4 cell count in 2014 among individuals starting cART in North America rose to 435/μL in 2014; at the other end of the spectrum, it was 186/μL in individuals starting cART in West Africa in the same year. In LICs, the estimated proportion of adults starting with severe immunodeficiency (= CD4 cell count <200/μL) declined from 95% in 2002 to 31% in 2015. Corresponding declines were from 75% to 40% in LMICs, from 79% to 26% in UMICs, and from 59% to 29% in HICs.
In conclusion, the study-results show that median CD4 cell counts at the start of cART have increased in all country income groups over the last few years, and the proportion of individuals starting cART with severe immunodeficiency has decreased. However, the median CD4 cell count at cART start generally remained below 350/μL in 2015 and the decline in severe immunodeficiency appears to have plateaued in some countries. Clearly, substantial additional efforts and resources will be needed to achieve early diagnosis, rapid linkage to care, and prompt initiation of cART globally.