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  IAS 2017: Conference on HIV Pathogenesis
Treatment and Prevention
Paris, France
July 23-26 2017
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CD4 Count at ART Start Rising Across Globe,
But Median Still Below 350 / 25% start at below 200 CD4

  9th IAS Conference on HIV Science (IAS 2017), July 23-26, 2017, Paris
from Jules: another reminder regarding reaching ENDING AIDS. Again I remind you Aging with HIV is not a nebulous problem but very real which will increase mortality & severely reduce quality of life, needs recognition & attention.
Mark Mascolini
Median CD4 count when antiretroviral therapy (ART) begins rose in low-, middle-, and high-income countries from 2002 through 2015, according to a huge two-cohort analysis [1]. But the median starting CD4 count remained below 350 across all country-income brackets.
World Health Organization (WHO) ART guidelines set the starting threshold at 200 CD4 cells in 2002-2009, raised that to 350 then 500 in 2009 and 2013, and began recommending ART for all with HIV in 2015. But researchers working with the IeDEA and COHERE cohorts noted that late HIV diagnosis and delayed guideline implementation mean many people with HIV start ART at CD4 counts well below 500.
To determine actual CD4 start levels, the researchers analyzed data from the IeDEA cohort (which includes people in Africa, Asia, Latin America, and North America) and COHERE (which includes people in Europe). They focused on adults starting ART from 2002 through 2015 and made multiple imputations for missing CD4 counts. For four income brackets (low, lower middle, upper middle, and high), they calculated median CD4 count at ART initiation and the percentage of people who started treatment with immunodeficiency, defined as a CD4 count below 200.
The analysis included 951,857 people in 16 low-income countries, 11 lower-middle countries, 9 upper-middle countries, and 19 high-income countries. Proportions of women across those four groups were 64%, 63%, 60%, and 25% (57% overall). Median starting age was 39 in high-income countries and 35 in the other income clusters.
Median starting CD4 count proved highest in high-income countries, rising from under 200 in 2002 to more than 300 in 2015. But lower- and middle-income countries had greater increases in starting CD4 count across the study years. Starting CD4 tally rose more in women than in men in lower- and middle-income countries, but not in high-income countries. By 2015 median starting CD4 count remained below 350 in all four income brackets.
Proportions of people beginning ART with fewer than 200 CD4s fell in all income clusters, with the greatest drops coming in low-income and upper-middle-income countries. The proportion starting ART with a sub-200 count fell most in women--except in high-income countries, in which the decline plateaued starting around 2010 in both women and men. By 2015 more than 25% of people across all regions still began ART with fewer than 200 CD4s.
The IeDEA/COHERE researchers concluded that the "real world" still lags current WHO start guidelines by "quite a bit." By 2015 none of the four regions has a median starting count above 350 CD4s, the threshold WHO cast aside in 2013. The investigators proposed that "substantial additional efforts and resources are needed to increase testing coverage with the aim of achieving earlier diagnosis, linkage to care, and initiation of cART globally."
1. Anderegg N, Kirk O. Immunodeficiency at the start of antiretroviral therapy in low-, middle- and high-income countries. 9th IAS Conference on HIV Science (IAS 2017), July 23-26, 2017, Paris. Abstract MOAB0101.