Proportion of people in southern Africa starting ART with advanced HIV disease falls

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.



In everyday language, a general movement upwards or downwards (e.g. every year there are more HIV infections). When discussing statistics, a trend often describes an apparent difference between results that is not statistically significant. 

linkage to care

Refers to an individual’s entry into specialist HIV care after being diagnosed with HIV. 

WHO stage

A simplified system to describe four clinical stages of HIV-related disease, based on clinical parameters (symptoms, weight loss and different opportunistic infections) rather than decreasing CD4 cell count. Stage I is asymptomatic, stage II mild symptoms, stage III advanced symptoms and stage IV severe symptoms (an AIDS diagnosis).

adjusted odds ratio (AOR)

Comparing one group with another, expresses differences in the odds of something happening. An odds ratio above 1 means something is more likely to happen in the group of interest; an odds ratio below 1 means it is less likely to happen. Similar to ‘relative risk’. 

loss to follow up

In a research study, participants who drop out before the end of the study. In routine clinical care, patients who do not attend medical appointments and who cannot be contacted.

An international 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 2011. 

Two-thirds of 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).

Throughout the 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).

Factors associated 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.”

The researchers 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.”


Lahuerta M et al. Advanced HIV disease into HIV care and initiation of antiretroviral therapy during 2006-2011: findings from four sub-Saharan African countries. Clin Infect Dis, online edition, 2013.