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.

Results:  A 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.