Sub-Saharan CD4 counts not rising

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A study by Harvard Medical School has found that the average CD4 count in sub-Saharan African people who are diagnosed with HIV has not risen since 2002. Neither has the average CD4 count on initiation of treatment, which remains well below the AIDS-defining limit of 200 cells/mm3.

Aidsmap reports that the authors call for far more active HIV testing and facilitated referral programmes, and continued global financial support for HIV testing and treatment.

The Harvard study looked at CD4 count on diagnosis and at initiation of antiretroviral therapy (ART) in 127 different studies covering over half a million patients between 2002 and 2012. Only six studies looked at CD4 count at both HIV diagnosis and ART initiation in the same patients.

It found that the average CD4 count at HIV diagnosis was 250 cells/mm3 in 2002 and 309 cells/mm3in 2012. This increase – amounting to a 5.8 cells cells/mm3 increase per year – was not statistically significant. The average CD4 count at ART initiation actually decreased very slightly, from 152 cells/mm3 in 2002 to 140 cells/mm3 in 2012, well below the Aids-defining limit of 200 cells/mm3. This decrease was also not significant.

There was no change in CD4 count at initiation after the issue of the World Health Organisation’s 2009 treatment guidelines, which changed the recommended CD4 count at which to start ART from 200 to 350 cells/mm3.

There were exceptions to these CD4 figures. When ART was given to pregnant women for the prevention of mother-to-child transmission, the CD4 count at diagnosis and at ART initiation were 395 and 313 cells/mm3 respectively.
More significantly in terms of general testing and treatment policy, CD4 counts were a lot higher at both diagnosis and ART initiation in so-called “active HIV screening” programmes. This means initiatives such as community-wide screening, community-based combination prevention programmes that include testing, home-testing and home-based testing by visiting health workers. In active programmes, CD4 counts at diagnosis and initiation were 405 and 268 cells/mm3respectively. However, only 3.3% of all the people whose CD4 counts were included were involved in studies of such programmes.

South Africa is the one country that had higher CD4 counts on diagnosis in 2012 than 2002: its year-on-year increase in average CD4 count at diagnosis of nearly 40 cells/mm3 a year would appear to be an endorsement of that country’s HIV awareness strategy. However this has not been matched by an increase in CD4 count at ART initiation, which at 123 cells/mm3 averaged over the whole decade is the second-lowest among countries surveyed after Ethiopia.

The researchers comment that there is a relative lack of data post-2010, with only 14% of studies reporting figures from beyond that year: this is because some multi-year studies do not report till the end, so recent improvements in CD4 count at diagnosis and ART initiation could be missed.

Full Aidsmap report
Clinical Infectious Diseases abstract
WHO treatment guidelines

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