Background. Early initiation of combination antiretroviral therapy (cART), at higher CD4 cell counts, prevents disease progression and reduces sexual transmission of human immunodefciency virus (HIV). We describe the temporal trends in CD4 cell counts at the start of cART in adults from low-income, lower-middle-income, upper-middle-income, and high-income countries (LICs, LMICs, UMICs, and HICs, respectively). Methods. We included HIV-infected individuals aged =16 years who started cART between 2002 and 2015 in a clinic participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) or the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE). Missing CD4 cell counts at the start of cART were estimated through multiple imputation. Weighted mixed-e?ect models were used to smooth trends in median CD4 cell counts. Results. A total of 951 855 adults from 16 LICs, 11 LMICs, 9 UMICs, and 19 HICs were included. Overall, the modeled median CD4 cell count at the start of cART increased from 2002 to 2015, from 78/μL (95% confdence interval, 58-104/μL) to 287/μL (250-328/μL) in LICs, from 99/μL (71-140/μL) to 234/μL (192-285/μL) in LMICs, from 71/μL (49-104/μL) to 311/μL (255-379/μL) in UMICs, and from 161/μL (143-181/μL) to 327/μL (286-372/μL) in HICs. In LICs, LMICs, and UMICs, the increase was more pronounced in women; in HICs, the opposite was observed. Conclusions. Median CD4 cell counts at the start of cART increased in all income groups, but generally remained below 350/μL in 2015. Substantial additional e?orts and resources are required to achieve earlier diagnosis, linkage to care, and initiation of cART.
