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

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/mu L between 2002 and 2009. Corresponding increases in LMIC, UMIC, and HIC were from 87 to 155 cells/mu L (76% increase), 88 to 135 cells/mu L (53%), and 209 to 274 cells/mu L (31%). In 2009, compared with LIC, median counts were 13 cells/mu L [95% confidence interval (CI): -56 to +30] lower in LMIC, 22 cells/mu L (-62 to +18) lower in UMIC, and 112 cells/mu L (+75 to +149) higher in HIC. They were 23 cells/mu L (95% CI: +18 to +28 cells/mu L) higher in women than men. Median counts were 88 cells/mu L (95% CI: +35 to +141 cells/mu L) higher in countries with an estimated national cART coverage >80%, compared with countries with Conclusions: Median CD4 cell counts at the start of cART increased 2000-2009 but remained below 200 cells/mu L in LIC and MIC and below 300 cells/mu L in HIC. Earlier start of cART will require substantial efforts and resources globally.