The proportion of people in sub-Saharan Africa who started antiretroviral therapy (ART) with
advanced HIV disease decreased significantly between 2006 and 2011, research published in the online edition of Clinical
Infectious Diseases shows. In 2011, 29% of patients had advanced disease
when they started ART compared to 42% in 2006. The average CD4 cell count at
the time of entry into HIV care also increased. However, the median CD4 cell
count at ART initiation increased only modestly, from 125 to 185 cells/mm3.
The investigators describe this rate of progress as “discouragingly slow” and add
that at the current rate it would take more than 15 years for the median CD4
cell count at the time of ART initiation to reach 350 cells/mm3.
The number of
people receiving ART in sub-Saharan Africa has increased dramatically, from
just 100,000 in 2003 to 6.2 million in 2011. But, despite this success in
expanding access to ART, most people living with HIV in this setting start
ART with advanced HIV disease (a CD4 cell count below 100 cells/mm3
or WHO stage 4 disease). This is associated with high rates of mortality and
contributes to the continued spread of HIV.
Most HIV treatment
guidelines in southern Africa now recommend that people living with HIV should start ART when
their CD4 cell count falls to below 350 cells/mm3 or if they have
WHO stage 3 or 4 disease.
team of investigators assessed trends in CD4 cell count at both the time of
entry into care and the initiation of ART, between 2006 and 2011 at 132 centres
in Kenya, Mozambique, Rwanda and Tanzania. They also examined the factors
associated with advanced HIV disease at the time of ART initiation in
patients who both enrolled in care and who started ART were women. Their median
age was 33-35 years.
The proportion of
people enrolling in care with a CD4 cell count below 100 cells/mm3
or WHO stage 4 disease, fell from 20% in 2006 to 18% in 2011 (trend, p <
0.001). Similarly, the proportion of people who started ART with advanced
disease decreased from 42 to 29% (trend, p < 0.001).
Median CD4 cell
count on entry to care increased from 238 cells/mm3 [106-438
cells/mm3] in 2006 to 286 cells/mm3 [127-482 cells/mm3]
in 2011 (trend, p < 0.001).
There was also a
significant increase in the median CD4 cell count at ART initiation, from 125
cells/mm3 [57-202 cell/mm3] at the start of the study to
185 cells/mm3 [86-279 cells/mm3] in 2011, an increase of
approximately 10 cells/mm3 each year (trend, p < 0.001).
study, men were significantly more likely to present with advanced disease than
women (2006, OR = 1.4; 95% CI, 1.3-1.5; 2011, OR = 1.6; 95% CI, 1.5-1.7).
Gender was also
associated with the late initiation of ART.
In 2011, men were
significantly more likely to initiate ART with advanced disease compared to
non-pregnant women (AOR= 1.4; 95% CI, 1.3-1.5). People taking TB treatment were
also more likely to start treatment late (AOR = 1.06; 95% CI,
1.3-2.0). People who were lost to follow-up for twelve or more months
between their entry into HIV care and initiating ART were also more likely to
start treatment with advanced disease compared to people who remained in
continuous HIV care (AOR = 2.0; 95% CI, 1.6-2.6).
with starting treatment without advanced HIV disease were older age, being
married or living with a partner, and for women diagnosis through services for
the prevention of mother-to-child transmission compared to diagnosis via
routine voluntary counselling and testing.
“Many clinics and
settings included in our analyses are making progress in treating the sickest
individuals in their catchment areas,” comment the authors. “But…intensified
and targeted efforts aimed at earlier diagnosis and linkage to care are needed.”
conclude: “interventions are needed to identify persons with undiagnosed HIV
earlier, to promote prompt linkage to care, to effectively enrol such
individuals in continuous care and monitor them for ART eligibility and once
eligible, to initiate them on ART in a timely manner.” They caution that
without these efforts “the full potential for impact of HIV programmatic
scale-up in the sub-Saharan African region may be diminished over the
long-term, both in terms of individual and public health benefits of preventing
onward HIV transmission.”