Although people with HIV worldwide are progressively starting treatment earlier in the course of their infection, the median CD4 count upon initiation of treatment with antiretrovirals (ARVs) remains below 350, the National AIDS Treatment Advocacy Project (NATAP) reports. This apparent delay in the typical treatment start point reveals that much more work is needed to adhere to World Health Organization (WHO) guidelines recommending treatment for all those living with the virus.
Between 2002 and 2009, WHO recommended starting HIV treatment when CD4 cells dropped to 200 or below. WHO raised this threshold to 350 in 2009 and 500 in 2013 before issuing the treat-all recommendation in 2015. The last recommendation followed the release of the findings from the landmark global START trial that proved definitively that starting HIV treatment with a CD4 count above 500 yields a net health benefit compared with waiting until CD4s drop to 350 or below.
To determine typical CD4 counts when people around the world start treatment, researchers analyzed data from the IeDEA cohort, which includes people with HIV in Africa, Asia, Latin America and North America, and the COHERE cohort, which covers Europe. They narrowed their analysis to adults beginning ARV treatment between 2002 and 2015. All told, 951,857 people were included in the analysis in 16 low-income, 11 lower-middle-income, nine upper-middle-income and 19 high-income nations.
Findings were presented at the 9th International AIDS Society Conference on HIV Science in Paris (IAS 2017).
Between 2002 and 2015, the median CD4 count at treatment initiation rose from below 200 to above 300 in high-income nations, yielding the highest median CD4 level among all income brackets at the end of the period. Meanwhile, the actual increases in median CD4 levels in lower- and middle-income nations were steeper during this period, even if they didn’t reach the CD4 levels seen among high-income nations. The rise was greater for women than men in lower- and middle-income countries but not in high-income nations.
All this success notwithstanding, by 2015 the median CD4 count when individuals began HIV treatment remained below 350 in all income brackets.
The proportion of people starting ARVs with a CD4 count below 200, which indicates an AIDS diagnosis, dropped during the study period across all income brackets. The greatest declines in this proportion occurred in low-income and upper-middle-income nations. The decline was the steepest among women, expect for those in high-income countries; in those nations, the decline leveled off beginning in about 2010 among both men and women.
Troublingly, in 2015, more than one in four people in all the regions studied still started HIV treatment with a CD4 count below 200.
To read the NATAP report, click here.