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Median CD4 count increase modest at ART initiation in sub-Saharan Africa
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The number of individuals in sub-Saharan Africa initiating antiretroviral therapy with advanced HIV disease has decreased, but the increase in median CD4 count at antiretroviral therapy initiation has been modest in that region, researchers said.
"Studies that have examined trends over time suggest that median CD4+ counts at ART initiation are increasing in most sub-Saharan African countries, but even in 2010 they remained below 200 cells/mcL in most low- and middle-income countries," Maria Lahuerta, PhD, MPH, an epidemiologist at Columbia University's International Center for AIDS Care and Treatment Programs, and colleagues wrote in Clinical Infectious Diseases.
Maria Lahuerta
The study included data on 334,557 adult patients enrolling in treatment programs and HIV care clinics. The cohort included a subset of 149,032 patients who initiated ART between 2006 and 2011 at 132 treatment facilities in Kenya, Mozambique, Rwanda and Tanzania. Lahuerta and colleagues looked at trends in advanced HIV disease — defined as a CD4 cell count of less than 100 cells/mcL or WHO disease stage IV— as well as factors related to advanced HIV disease among patients who initiated treatment in 2011 (n=20,366).
From 2006 to 2011, the median CD4 count at enrollment increased from 238 cells/mcL (interquartile range [IQR], 106-436) to 286 cells/mcL (IQR, 127-482; P<.001). The median CD4 count also increased at ART initiation from 125 cells/mcL (IQR, 57-202) to 185 cells/mcL (IQR, 86-279; P<.001), corresponding to an increase of 10 cells per year.
Among those who initiated ART between 2006 and 2011, 29% had advanced HIV disease at enrollment, and 35% had advanced HIV disease at ART initiation, "suggesting that most of those who initiated ART [with] advanced HIV disease did so because they had enrolled in care with advanced HIV disease," according to the researchers.
The proportion of HIV patients with advanced disease who initiated ART decreased from 42% to 29% (P<.001) during the study period, but the researchers observed a significant gender gap. For example, men were significantly more likely than women to have advanced HIV disease at the time of treatment initiation, a disparity that widened between 2006 (OR=1.4; 95% CI, 1.3-1.5) and 2011 (OR=1.6; 95% CI, 1.5-1.7).
In 2011, determinants of advanced HIV disease included male gender (adjusted OR=1.4; 95% CI, 1.3-1.5), tuberculosis treatment at ART initiation (adjusted OR=1.6; 95% CI, 1.3-2), and experiencing a gap in care of more than 12 months before ART initiation (adjusted OR=2; 95% CI, 1.6-2.6). Lower odds were observed for those who enrolled in HIV care through prevention of mother-to-child transmission services as opposed to voluntary counseling and testing (adjusted OR=0.66; 95% CI, 0.55-0.8).
Although the increase in the median CD4 count is encouraging, the researchers described the rate of that increase as "discouragingly slow," and that if trends continue at the rate of 10 cells per year, it would be more than 15 years before the median CD4 count in their sample of 132 clinics reached 350 cells/mcL — the current recommended CD4 count threshold for ART initiation in most sub-Saharan African countries.
"This study suggests that improving retention in pre-ART care coupled with adequate CD4 monitoring can result in more timely ART initiation," Lahuerta told Infectious Disease News. "Strategies are needed to promote earlier diagnosis and ART initiation, especially among males."
— John Schoen
Maria Lahuerta, PhD, MPH can be reached at ml2842@columbia.edu.
Disclosure: Lahuerta reports no relevant financial disclosures.
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