Global Trends in CD4 Cell Count at the Start of Antiretroviral Therapy: Collaborative Study of Treatment Programs

The IeDEA and COHERE Cohort Collaborations

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Background. Early initiation of combination antiretroviral therapy (cART), at higher CD4 cell counts, prevents disease progression and reduces sexual transmission of human immunodefciency virus (HIV). We describe the temporal trends in CD4 cell counts at the start of cART in adults from low-income, lower-middle-income, upper-middle-income, and high-income countries (LICs, LMICs, UMICs, and HICs, respectively). Methods. We included HIV-infected individuals aged =16 years who started cART between 2002 and 2015 in a clinic participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) or the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE). Missing CD4 cell counts at the start of cART were estimated through multiple imputation. Weighted mixed-e?ect models were used to smooth trends in median CD4 cell counts. Results. A total of 951 855 adults from 16 LICs, 11 LMICs, 9 UMICs, and 19 HICs were included. Overall, the modeled median CD4 cell count at the start of cART increased from 2002 to 2015, from 78/μL (95% confdence interval, 58-104/μL) to 287/μL (250-328/μL) in LICs, from 99/μL (71-140/μL) to 234/μL (192-285/μL) in LMICs, from 71/μL (49-104/μL) to 311/μL (255-379/μL) in UMICs, and from 161/μL (143-181/μL) to 327/μL (286-372/μL) in HICs. In LICs, LMICs, and UMICs, the increase was more pronounced in women; in HICs, the opposite was observed. Conclusions. Median CD4 cell counts at the start of cART increased in all income groups, but generally remained below 350/μL in 2015. Substantial additional e?orts and resources are required to achieve earlier diagnosis, linkage to care, and initiation of cART.

Original languageEnglish
Pages (from-to)893-903
Number of pages11
JournalClinical Infectious Diseases
Issue number6
Publication statusPublished - 5 Mar 2018

Bibliographical note

Funding Information:
Financial support. The African regions for IeDEA are supported by the National Cancer Institute, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and the National Institute of Allergy and Infectious Diseases (NIAID) as part of the IeDEA (grants U01AI069919, U01AI069924, U01AI096299, and U01AI069911). The Caribbean, Central, and South America Network for HIV Epidemiology (CCASAnet), a member cohort of IeDEA (grant U01AI069923), is funded by the following institutes: NICHD, Office of the Director, NIH, NIAID, the National Cancer Institute, and the National Institute of Mental Health. The North American AIDS Cohort Collaboration on Research and Design of IeDEA is supported by the NIH (grants U01AI069918, F31DA037788, G12MD007583, K01AI093197, K23EY013707, K24AI065298, K24AI118591, K24DA000432, KL2TR000421, M01RR000052, N01CP01004, N02CP055504, N02CP91027, P30AI027757, P30AI027763, P30AI027767, P30AI036219, P30AI050410, P30AI094189, P30AI110527, P30MH62246, R01AA016893, R01AG053100, R01CA165937, R01DA011602, R01DA012568, R24AI067039, U01AA013566, U01AA020790, U01AI031834, U01AI034989, U01AI034993, U01AI034994, U01AI035004, U01AI035039, U01AI035040, U01AI035041, U01AI035042, U01AI037613, U01AI037984, U01AI038855, U01AI038858, U01AI042590, U01AI068634, U01AI068636, U01AI069432, U01AI069434, U01AI103390, U01AI103397, U01AI103401, U01AI103408, U01DA03629, U01DA036935, U01HD032632, U10EY008057, U10EY008052, U10EY008067, U24AA020794, U54MD007587, UL1RR024131, UL1TR000004, UL1TR000083, UL1TR000454, UM1AI035043, Z01CP010214, and Z01CP010176); the US Centers for Disease Control and Prevention (CDC; contracts CDC-200-2006-18797 and CDC-200-2015-63931); from the US Agency for Healthcare Research and Quality (contract 90047713); from the US Health Resources and Services Administration (contract 90051652); the Canadian Institutes of Health Research (grants CBR-86906, CBR-94036, HCP-97105, and TGF-96118); Ontario Ministry of Health and Long Term Care; and the Government of Alberta, Canada. Additional support was provided by the National Cancer Institute, National Institute for Mental Health, and National Institute on Drug Abuse. The TREAT Asia HIV Observational Database and the Australian HIV Observational Database are initiatives of TREAT Asia, a program of amfAR, The Foundation for AIDS Research, with support from the NIAID, the NICHD, the National Cancer Institute, the National Institute of Mental Health, and the National Institute on Drug Abuse, as part of IeDEA (grant U01AI069907). The Kirby Institute is funded by the Australian Government Department of Health and Ageing and affiliated with the Faculty of Medicine, UNSW Sydney.

Publisher Copyright:
© 2017 The Author(s).


  • CD4 cell count
  • WHO guidelines
  • antiretroviral therapy


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