Immunodeficiency at the Start of ART: Global View
C Mugglin1, K Althoff2, K Wools-Kaloustian3, J Sterne4, D Nash5, F Dabis6, C Williams7, C McGowan8, D Cooper9, Matthias Egger*1, and IeDEA and ART-CC Collaborations
1Univ of Bern, Switzerland; 2Johns Hopkins Univ Bloomberg Sch of Publ Hlth, Baltimore, MD, US; 3Indiana Univ Sch of Med, Indianapolis, US; 4Univ of Bristol Sch of Social and Community Med, UK; 5CUNY Sch of Publ Hlth at Hunter Coll, New York, NY, US; 6INSERM U897, Bordeaux Sch of Publ Hlth, Univ Bordeaux Segalen, France; 7NIAID, NIH, Bethesda, MD, US; 8Vanderbilt Univ, Nashville, TN, US; and 9Univ of New South Wales, Sydney, Australia
Background: Early initiation of ART, at higher CD4 T cell counts, prevents progression and reduces sexual transmission of HIV-1. We describe the CD4 count at the start of ART in 5 continents.
Methods: Data are from the International epidemiologic Databases to Evaluate AIDS (IeDEA) and Western European cohorts in the ART Cohort Collaboration (ART-CC). IeDEA has networks in North America; the Caribbean, Central and South America (CCASA); Asia Pacific and West, Central, East, and Southern Africa. Patients aged >16 years with known CD4 count at start of ART, age, and sex were eligible. Analyses were stratified by World Bank country classification and gender.
total of 309,435 patients from 48 countries were eligible: 222,980
patients from sub-Saharan Africa (20 countries), 58,880 from Europe (7), 16,733
from North America (2), 5,797 from Asia/Pacific (12), and 5,045 from CCASA (7).
Trends in median CD4 counts at start of ART from 2002, when ART was scaled up
globally, were similar in low-income and upper middle-income countries (table).
Median counts were higher in lower middle-income and highest in high-income
countries. Changes were notable in sites from Burkina Faso (+132 cells/µL), Rwanda (+117 cells/µL), and Haiti (–81 cells/µL). Fifteen countries reached median CD4 counts
≥200 cells/µL: Australia, Brazil, Burkina Faso, Cambodia, Canada, France, Germany, Italy, Mozambique, Netherlands, Rwanda, Spain, Switzerland, UK, and USA. No country reached counts ≥350 cells/µL. In all except
high-income countries, median counts were higher and increased to a greater
extent in women than men.
*Data from 2009
Conclusions: Median CD4 count at start of ART increased in most countries, but remained below 200 cells/µL in low- and middle-income countries in 2010. Substantial effort and resources are needed to achieve earlier implementation of ART globally.