title: Baseline CD4 Count and Adherence to Antiretroviral Therapy: A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  In light of recent changes to antiretroviral treatment (ART) guidelines of the World Health Organization and ongoing concerns about adherence with earlier initiation of ART, we conducted a systematic review of published literature to review the association between baseline (pre-ART initiation) CD4 count and ART adherence among adults enrolled in ART programs worldwide.
  
  
  METHODS
  We performed a systematic search of English language original studies published between January 1, 2004 and September 30, 2015 using Medline, Web of Science, LILACS, AIM, IMEMR, and WPIMR databases. We calculated the odds of being adherent at higher CD4 count compared with lower CD4 count according to study definitions and pooled data using random effects models.
  
  
  RESULTS
  Twenty-eight articles were included in the review and 18 in the meta-analysis. The odds of being adherent was marginally lower for patients in the higher CD4 count group (pooled odds ratio, 0.90; 95% confidence interval, 0.84 to 0.96); however, the majority of studies found no difference in the odds of adherence when comparing CD4 count strata. In analyses restricted to comparisons above and below a CD4 count of 500 cells per microliter, there was no difference in adherence (pooled odds ratio, 1.01; 95% confidence interval: 0.97 to 1.05).
  
  
  CONCLUSIONS
  This review was unable to find consistent evidence of differences in adherence according to baseline CD4 count. Although this is encouraging for the new recommendations to treat all HIV-positive individuals irrespective of CD4 count, there is a need for additional high-quality studies, particularly among adults initiating ART at higher CD4 cell counts.
authors.affiliation: *Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa;†Independent consultant;‡Department of Health, Western Cape Government, Cape Town, South Africa;§London School of Hygiene and Tropical Medicine, London, United Kingdom;‖Precision Global Health, Vancouver, Canada;¶Department of Medicine, Clinical Trial Units, Imperial College, London, United Kingdom;#Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; and**Division of infectious diseases, Imperial College London, London, United Kingdom.
authors.forename: Peter
authors.initials: P
authors.lastname: Bock
authors.forename: Anelet
authors.initials: A
authors.lastname: James
authors.forename: Alliance
authors.initials: A
authors.lastname: Nikuze
authors.forename: Neshaan
authors.initials: N
authors.lastname: Peton
authors.forename: Kalpana
authors.initials: K
authors.lastname: Sabapathy
authors.forename: Edward
authors.initials: E
authors.lastname: Mills
authors.forename: Sarah
authors.initials: S
authors.lastname: Fidler
authors.forename: Nathan
authors.initials: N
authors.lastname: Ford
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000473:pathology*; D006801:Humans; D055118:Medication Adherence
chemical_list: D044966:Anti-Retroviral Agents