How to Evolve the Response to the Global HIV Epidemic With New Metrics and Targets Based on Pre-Treatment CD4 Counts
Purpose of the Review
Early diagnosis and treatment of HIV following seroconversion improves individual and population health. Using published data on pre-treatment CD4 cell counts, we benchmarked the level of immunodeficiency at HIV diagnosis and ART initiation in the “real world” against those of the treatment and control arms of landmark controlled trials that successfully reduced HIV-related deaths (INSIGHT/START) and onward HIV transmission (HPTN 052).
The median CD4 count in the treatment vs. control arms of the INSIGHT/START trial and HPTN 052 were 650 vs. 408 cells/μL and 442 vs. 221 cells/μL, respectively. In the real world, recent global estimates of the median CD4 count at start of ART range from 234 to 350 cells/μL, and only 25% of those initiating ART do so early (i.e., with CD4 > 500 cells/μL). Recent global data on trends in the median CD4 count at diagnosis and ART initiation are not encouraging.
We identify a critical need for new targets and metrics for persons newly diagnosed with HIV, newly enrolling in HIV care, and newly initiating ART, based on pre-treatment CD4 counts, to help increase the focus of implementation efforts on achieving earlier diagnosis, linkage to care, and ART initiation.
KeywordsPre-treatment CD4 count Implementation science Metrics 90-90-90 targets Treatment as prevention
The authors would like to acknowledge Rebecca Zimba and Julia A. Schillinger for their thoughts and comments on the drafts of our manuscript.
DN was supported by a funding from the US National Institutes of Health, including Central Africa IeDEA (U01AI096299), the Einstein, Rockefeller, CUNY Center for AIDS Research (ERC CFAR, P30 AI124414), and the HIV Center for Clinical and Behavioral Studies (P30 MH043520). DN and MR were both supported by the CUNY Institute for Implementation Science in Population Health.
Compliance with Ethical Standards
Conflict of Interest
Dr. Nash reports grants from NIH, during the conduct of the study. Ms. Robertson has nothing to disclose.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
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