It has become increasingly clear that antiretroviral therapy (ART) should be started before CD4 counts have dropped to low levels in order to optimize clinical benefits and recovery of the immune system. In 2010, the World Health Organization adjusted its treatment guidelines to recommend that, even in the absence of symptoms, HIV-infected people should be started on ART if their CD4 levels drop below 350 cells/mm3. However, studies from both developed and developing countries show that many people infected with HIV do not start ART until their CD4 counts have dropped far below this threshold.
Researchers in China recently examined trends in the levels of CD4 counts of patients starting ART under China's National Free ART Program.1 They analyzed data from 49,321 patients who started ART between July 2006 and December 2009. Even though the CD4 count before starting ART increased over this period, 30 percent of the patients still accessed ART at a very late stage in 2009, with CD4 levels below 50 cells/mm3. At the beginning of the study period, from July to December 2006, the median CD4 count before starting ART was 100 cells/mm3. Between July and December 2009, this number increased significantly, notably as a result of an increase in the proportion of patients started on ART at CD4 levels between 200 and 350 cells/mm3, but the baseline median CD4 count before starting ART remained as low as 150 cells/ mm3.
The study team observed that factors associated with starting ART after CD4 counts had fallen to low levels included being male, single, having been infected through heterosexual contact, and having been recently diagnosed with HIV. In contrast, patients infected through intravenous drug use or homosexual contact tended to have started ART at higher CD4 levels. It was noted that the average time between diagnosis of HIV infection and starting ART did not change significantly between 2006 and 2009.
These findings illustrate that despite some improvements in earlier initiation of ART in China, the majority of patients continue to access ART late, when their CD4 levels have already fallen to low or very low levels. In addition, people with HIV are diagnosed long after most of them become infected with the virus. Greater efforts in China and across the region should focus on strengthening HIV testing services in order to facilitate earlier ART initiation, thereby maximizing its health benefits to patients.
1. Yi Wen, Decai Zhao, Zhihui Dou, Ye Ma, Yan Zhao, Lin Lu, Wei Liu, Hao Zhu, and Fujie Zhang. Some patient-related factors associated with late access to ART in China’s free ART program. AIDS Care. 2011 Oct; 23(10):1226-35. Epub 2011 Jun 21.