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. 2025 Jul 18;80(6):1332-1336.
doi: 10.1093/cid/ciae548.

Global Trends in CD4 Count Measurement and Distribution at First Antiretroviral Treatment Initiation

Reneé de Waal  1 , Kara Wools-Kaloustian  2 , Ellen Brazier  3 , Keri N Althoff  4 , Antoine Jaquet  5 , Stephany N Duda  6 , Nagalingeswaran Kumarasamy  7 , Theodora Savory  8 , Helen Byakwaga  9 , Gad Murenzi  10 , Amy Justice  11 , Didier K Ekouevi  12 , Carina Cesar  13 , Mark K U Pasayan  14 , Agness Thawani  15 , Charles Kasozi  16 , Pelagie Babakazo  17 , Maile Karris  18 , Eugene Messou  19 , Claudia P Cortes  20 , Cordelia Kunzekwenyika  21 , Jun Yong Choi  22 , Noela C Owarwo  23 , Annabelle Niyongabo  24 , Vincent C Marconi  25 , Oliver Ezechi  26 , Jessica L Castilho  27 , Kathy Petoumenos  28 , Leigh F Johnson  1 , Nathan Ford  1   29 , Reshma Kassanjee  1
Affiliations

Global Trends in CD4 Count Measurement and Distribution at First Antiretroviral Treatment Initiation

Reneé de Waal et al. Clin Infect Dis. .

Abstract

Background: While people with human immunodeficiency virus (PWH) start antiretroviral treatment (ART) regardless of CD4 count, CD4 measurement remains crucial for detecting advanced human immunodeficiency virus (HIV) disease and evaluating ART programs. We explored CD4 measurement (proportion of PWH with a CD4 result available) and prevalence of CD4 <200 cells/µL (hereafter "CD4 <200") at ART initiation within the International epidemiology Databases to Evaluate AIDS (IeDEA) global collaboration.

Methods: We included PWH at participating ART programs who first initiated ART at age 15-80 years during 2005-2019. We described proportions of PWH with a CD4 result (measured within 6 months before to 2 weeks after ART initiation) and, among those with a CD4 result, with CD4 <200, by year of ART initiation and region.

Results: We included 1 355 104 PWH from 42 countries in 7 regions; 63% were female. The median (interquartile range) age at ART initiation was 37 (3144) years in males and 32 (26-39) years in females. CD4 measurement initially increased, or remained stable over time until around 2013, but then declined to low levels in some regions (Southern Africa, except South Africa: from 54% to 13%; East Africa: 85% to 31%; Central Africa: 72% to 20%; West Africa: 91% to 53%; and Latin America: 87% to 56%). Prevalence of CD4 <200 declined over time in all regions, but plateaued after 2015 at ≥30%.

Conclusions: CD4 measurement has declined sharply in recent years, especially in sub-Saharan Africa. Among those with a CD4 measurement, the prevalence of CD4 <200 remains concerningly high. Scaling up CD4 testing and securing adequate funding are urgent priorities.

Keywords: Advanced HIV disease; CD4 at ART start; Global testing trends; HIV care; Treat-All.

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Conflict of interest statement

Potential conflicts of interest. For work unrelated to this manuscript, the following authors or their institutions received support from Bayer (V. C. M.); Eli Lilly (V. C. M.); Gilead Sciences (K. P., M. K., and V. C. M.); GSK (C. P. C.); Merck/MSD (C. P. C. and V. C. M.); ViiV Healthcare (C. P. C., K. P., M. K., and V. C. M.); Coursera (K. N. A.); World Health Organization (D. K. E.); Centers for Disease Control and Prevention (V. C. M.); NIH (C. P. C., J. L. C., K. N. A., and V. C. M.); and Veterans Affairs (V. C. M.). The following authors are or were members of boards, societies, committees, or advocacy groups: C. P. C. (International AIDS Society General Council); M. K. (AIDS Clinical Trials Group [ACTG] Underrepresented Populations Committee, ACTG HIV and Aging Work Group, Being Alive San Diego); N. C. O. (With Love Uganda); and V. C. M. (NIH study section; data safety monitoring or advisory board: IL-1b study, CLEAR HIV, VB201, Outsmart, ECLIPSE). All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Figures

Graphical Abstract
Graphical Abstract
This graphical abstract is also available at Tidbit: https://tidbitapp.io/tidbits/global-trends-in-cd4-count-measurement-and-distribution-at-first-antiretroviral-treatment-initiation?utm_campaign=tidbitlinkshare&utm_source=ITP
Figure 1.
Figure 1.
CD4 measurement and distribution at antiretroviral treatment (ART) initiation in people with human immunodeficiency virus (PWH) at International epidemiology Databases to Evaluate AIDS (IeDEA)–participating treatment programs: percentage of PWH initiating ART for whom there is a documented CD4 measurement (A); among those with a documented CD4 measurement, the percentage with CD4 count <200 cells/μL (B); and, among those with a documented CD4 measurement, the CD4 count median (solid line), first to third quartiles (darker shaded ribbon), and 5th and 95th percentiles (dashed lines) (C). Shaded gray areas represent the “Treat-All” era from September 2015 based on World Health Organization guidelines. aExcluding South Africa. Abbreviations: ART, antiretroviral treatment; CI, confidence interval.
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