Background: Early initiation of combination antiretroviral therapy (cART), at higher CD4 cell counts, prevents disease progression and reduces sexual transmission of HIV. Changes in guidelines are expected to result in increased CD4 cell counts at cART start. We describe temporal trends in the median CD4 cell count at cART start in adult men and women.
Methods: We used data from the International epidemiology Databases to Evaluate AIDS (IeDEA) sub-Saharan Africa, Latin America, Asia-Pacific and North America regions and from the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE). We included all HIV-positive adults (≥16 years) initiating cART between 2002 and 2015. We aggregated data by calendar year, country and sex, and calculated median CD4 cell counts for each of the data cells. We used additive mixed models to analyze temporal trends in median CD4 cell counts. Sex, country income group and their interaction were included as fixed effects, and yearly trends were smoothed by sex and country income group.
Results: We included 652,728 adults from 14 low-, 11 lower middle-, 6 upper middle-, and 17 high-income countries. The Figure shows the modelled median CD4 cell count (cells/µL): from 2002-2015 there was an increase from 66 to 243 (+268%) in low-, from 88 to 170 (+93%) in lower middle-, from 69 to 257 (+272%) in upper middle- and from 163 to 355 (+118%) in high-income countries in males; and from 78 to 309 (+296%) in low-, 118 to 264 (+124%) in lower middle-, 70 to 328 (+369%) in upper middle- and 170 to 302 (+78%) in high-income countries in females.
Conclusions: Median CD4 cell count at cART start increased in all income groups, but generally remained below 350 cells/µL. Substantial additional efforts are needed to increase testing coverage with the aim of achieving earlier diagnosis, linkage, and initiation of cART globally.

Modelled trends in CD4 cell count at cART start
[Modelled trends in CD4 cell count at cART start]