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. 2014 Jan 1;65(1):e8-16.
doi: 10.1097/QAI.0b013e3182a39979.

Immunodeficiency at the start of combination antiretroviral therapy in low-, middle-, and high-income countries

IeDEA and ART Cohort Collaborations; Dorita Avila, Keri N Althoff, Catrina Mugglin, Kara Wools-Kaloustian, Manuel Koller, François Dabis, Denis Nash, Thomas Gsponer, Somnuek Sungkanuparph, Catherine McGowan, Margaret May, David Cooper, Cleophas Chimbetete, Marcelo Wolff, Ann Collier, Hamish McManus, Mary-Ann Davies, Dominique Costagliola, Brenda Crabtree-Ramirez, Romanee Chaiwarith, Angela Cescon, Morna Cornell, Lameck Diero, Praphan Phanuphak, Adrien Sawadogo, Jochen Ehmer, Serge P Eholie, Patrick C K Li, Matthew P Fox, Neel R Gandhi, Elsa González, Christopher K C Lee, Christopher J Hoffmann, Andrew Kambugu, Olivia Keiser, Rossana Ditangco, Hans Prozesky, Fiona Lampe, Nagalingeswaran Kumarasamy, Mari Kitahata, Emmanuel Lugina, Rita Lyamuya, Saphonn Vonthanak, Valeria Fink, Antonella d'Arminio Monforte, Paula Mendes Luz, Yi-Ming A Chen, Albert Minga, Jordi Casabona, Albert Mwango, Jun Y Choi, Marie-Louise Newell, Elizabeth A Bukusi, Kapella Ngonyani, Tuti P Merati, Juliana Otieno, Mwebesa B Bosco, Sam Phiri, Oon T Ng, Kathryn Anastos, Jürgen Rockstroh, Ignacio Santos, Shinichi Oka, Geoffrey Somi, Christoph Stephan, Ramon Teira, Deo Wabwire, Gilles Wandeler, Andrew Boulle, Peter Reiss, Robin Wood, Benjamin H Chi, Carolyn Williams, Jonathan A Sterne, Matthias Egger

Immunodeficiency at the start of combination antiretroviral therapy in low-, middle-, and high-income countries

IeDEA and ART Cohort Collaborations et al. J Acquir Immune Defic Syndr. .

Abstract

Objective: To describe the CD4 cell count at the start of combination antiretroviral therapy (cART) in low-income (LIC), lower middle-income (LMIC), upper middle-income (UMIC), and high-income (HIC) countries.

Methods: Patients aged 16 years or older starting cART in a clinic participating in a multicohort collaboration spanning 6 continents (International epidemiological Databases to Evaluate AIDS and ART Cohort Collaboration) were eligible. Multilevel linear regression models were adjusted for age, gender, and calendar year; missing CD4 counts were imputed.

Results: In total, 379,865 patients from 9 LIC, 4 LMIC, 4 UMIC, and 6 HIC were included. In LIC, the median CD4 cell count at cART initiation increased by 83% from 80 to 145 cells/μL between 2002 and 2009. Corresponding increases in LMIC, UMIC, and HIC were from 87 to 155 cells/μL (76% increase), 88 to 135 cells/μL (53%), and 209 to 274 cells/μL (31%). In 2009, compared with LIC, median counts were 13 cells/μL [95% confidence interval (CI): -56 to +30] lower in LMIC, 22 cells/μL (-62 to +18) lower in UMIC, and 112 cells/μL (+75 to +149) higher in HIC. They were 23 cells/μL (95% CI: +18 to +28 cells/μL) higher in women than men. Median counts were 88 cells/μL (95% CI: +35 to +141 cells/μL) higher in countries with an estimated national cART coverage >80%, compared with countries with <40% coverage.

Conclusions: Median CD4 cell counts at the start of cART increased 2000-2009 but remained below 200 cells/μL in LIC and MIC and below 300 cells/μL in HIC. Earlier start of cART will require substantial efforts and resources globally.

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Conflict of interest statement

CONFLICTS: The authors declare that they have no conflicts of interest.

Figures

Figure 1
Figure 1
Flow chart of patients included and excluded from analyses.
Figure 2
Figure 2
Trends of median CD4 cell counts at the start of cART (upper panel) and in proportions of men and women starting cART below 200 cells/μl (middle panel) or below 100 cells/μl (lower panel) in low, middle and high income countries, 2002 to 2010. The shaded areas represent the 95% confidence intervals for each year. Results from mixed effects linear regression (model 3) based on 379,865 patients, missing values imputed using multiple imputation.
See this image and copyright information in PMC

Comment in

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