title: Trends in CD4 count at presentation to care and treatment initiation in sub-Saharan Africa, 2002-2013: a meta-analysis.
abstract: BACKGROUND
  Both population- and individual-level benefits of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) are contingent on early diagnosis and initiation of therapy. We estimated trends in disease status at presentation to care and at ART initiation in sub-Saharan Africa.
  
  
  METHODS
  We searched PubMed for studies published January 2002-December 2013 that reported CD4 cell count at presentation or ART initiation among adults in sub-Saharan Africa. We abstracted study sample size, year(s), and mean CD4 count. A random-effects meta-regression model was used to obtain pooled estimates during each year of the observation period.
  
  
  RESULTS
  We identified 56 articles reporting CD4 count at presentation (N = 295 455) and 71 articles reporting CD4 count at ART initiation (N = 549 702). The mean estimated CD4 count in 2002 was 251 cells/µL at presentation and 152 cells/µL at ART initiation. During 2002-2013, neither CD4 count at presentation (β = 5.8 cells/year; 95% confidence interval [CI], -10.7 to 22.4 cells/year), nor CD4 count at ART initiation (β = -1.1 cells/year; 95% CI, -8.4 to 6.2 cells/year) increased significantly. Excluding studies of opportunistic infections or prevention of mother-to-child transmission did not alter our findings. Among studies conducted in South Africa (N = 14), CD4 count at presentation increased by 39.9 cells/year (95% CI, 9.2-70.2 cells/year; P = .02), but CD4 count at ART initiation did not change.
  
  
  CONCLUSIONS
  CD4 counts at presentation to care and at ART initiation in sub-Saharan Africa have not increased over the past decade. Barriers to presentation, diagnosis, and linkage to HIV care remain major challenges that require attention to optimize population-level benefits of ART.
authors.affiliation: Center for Global Health Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital Harvard Medical School.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Siedner
authors.affiliation: Center for Global Health.
authors.forename: Courtney K
authors.initials: CK
authors.lastname: Ng
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital Harvard Medical School Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital.
authors.forename: Ingrid V
authors.initials: IV
authors.lastname: Bassett
authors.affiliation: Center for Global Health Harvard Medical School Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Ingrid T
authors.initials: IT
authors.lastname: Katz
authors.affiliation: Center for Global Health Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital Harvard Medical School Mbarara University of Science and Technology, Uganda.
authors.forename: David R
authors.initials: DR
authors.lastname: Bangsberg
authors.affiliation: Center for Global Health Harvard Medical School Mbarara University of Science and Technology, Uganda Department of Psychiatry, Massachusetts General Hospital, Boston.
authors.forename: Alexander C
authors.initials: AC
authors.lastname: Tsai
mesh_terms: D000293:Adolescent; D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D000368:Aged; D019380:Anti-HIV Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology* / Q000276:immunology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents
keywords: HIV/AIDS; antiretroviral therapy; linkage to care; meta-analysis; sub-Saharan Africa