Immunodeficiency at the start of combination antiretroviral therapy in low-, middle-, and high-income countries

Dorita Avila, Keri N Althoff, Catrina Mugglin, Kara Wools-Kaloustian, Manuel Koller, François Dabis, Denis Nash, Thomas Gsponer, Somnuek Sungkanuparph, Catherine McGowan, Margaret May, David Cooper, Cleophas Chimbetete, Marcelo Wolff, Ann Collier, Hamish McManus, Mary-Ann Davies, Dominique Costagliola, Brenda Crabtree-Ramirez, Romanee ChaiwarithAngela Cescon, Morna Cornell, Lameck Diero, Praphan Phanuphak, Adrien Sawadogo, Jochen Ehmer, Serge P Eholie, Patrick C K Li, Matthew P Fox, Neel R Gandhi, Elsa González, Christopher K C Lee, Christopher J Hoffmann, Andrew Kambugu, Olivia Keiser, Rossana Ditangco, Hans Prozesky, Fiona Lampe, Nagalingeswaran Kumarasamy, Mari Kitahata, Emmanuel Lugina, Rita Lyamuya, Saphonn Vonthanak, Valeria Fink, Antonella d'Arminio Monforte, Paula Mendes Luz, Yi-Ming A Chen, Albert Minga, Jonathan A Sterne, Matthias Egger, IeDEA and ART Cohort Collaborations

Research output: Contribution to journalArticle (Academic Journal)peer-review

115 Citations (Scopus)


OBJECTIVE: To describe the CD4 cell count at the start of combination antiretroviral therapy (cART) in low-income (LIC), lower middle-income (LMIC), upper middle-income (UMIC), and high-income (HIC) countries.

METHODS: Patients aged 16 years or older starting cART in a clinic participating in a multicohort collaboration spanning 6 continents (International epidemiological Databases to Evaluate AIDS and ART Cohort Collaboration) were eligible. Multilevel linear regression models were adjusted for age, gender, and calendar year; missing CD4 counts were imputed.

RESULTS: In total, 379,865 patients from 9 LIC, 4 LMIC, 4 UMIC, and 6 HIC were included. In LIC, the median CD4 cell count at cART initiation increased by 83% from 80 to 145 cells/μL between 2002 and 2009. Corresponding increases in LMIC, UMIC, and HIC were from 87 to 155 cells/μL (76% increase), 88 to 135 cells/μL (53%), and 209 to 274 cells/μL (31%). In 2009, compared with LIC, median counts were 13 cells/μL [95% confidence interval (CI): -56 to +30] lower in LMIC, 22 cells/μL (-62 to +18) lower in UMIC, and 112 cells/μL (+75 to +149) higher in HIC. They were 23 cells/μL (95% CI: +18 to +28 cells/μL) higher in women than men. Median counts were 88 cells/μL (95% CI: +35 to +141 cells/μL) higher in countries with an estimated national cART coverage >80%, compared with countries with <40% coverage.

CONCLUSIONS: Median CD4 cell counts at the start of cART increased 2000-2009 but remained below 200 cells/μL in LIC and MIC and below 300 cells/μL in HIC. Earlier start of cART will require substantial efforts and resources globally.

Original languageEnglish
Pages (from-to)e8-16
JournalJournal of Acquired Immune Deficiency Syndromes
Issue number1
Publication statusPublished - 1 Jan 2014


  • Adolescent
  • Adult
  • Age Factors
  • Anti-HIV Agents
  • CD4 Lymphocyte Count
  • Developed Countries
  • Developing Countries
  • Female
  • HIV Infections
  • Humans
  • Male
  • Sex Factors
  • Young Adult

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