Morbidity and Mortality Weekly Report 
Trends in Prevalence of Advanced HIV Disease at Antiretroviral Therapy 
Enrollment — 10 Countries, 2004–2015
Andrew F. Auld, MBChB1; Ray W. Shiraishi, PhD1; Ikwo Oboho, MD1; Christine Ross, MD1; Moses Bateganya, MD1; Valerie Pelletier, MD2; 
Jacob Dee, MPH1; Kesner Francois, MD3; Nirva Duval, MD3; Mayer Antoine, MD2; Chris Delcher, PhD4; Gracia Desforges, MD3; Mark Griswold, 
MSc4; Jean Wysler Domercant, MD2; Nadjy Joseph, MD3; Varough Deyde, PhD2; Yrvel Desir, MSc4; Joelle Deas Van Onacker, MD3; Ermane Robin, 
MD3; Helen Chun, MD1; Isaac Zulu, MD1; Ishani Pathmanathan, MD1; E. Kainne Dokubo, MD1; Spencer Lloyd, MD1; Rituparna Pati, MD1; 
Jonathan Kaplan, MD1; Elliot Raizes, MD1; Thomas Spira, MD1; Kiren Mitruka, MD1; Aleny Couto, MD5; Eduardo Samo Gudo, MD5; Francisco 
Mbofana, MD6; Melissa Briggs, MD7; Charity Alfredo, MD7; Carla Xavier7; Alfredo Vergara, PhD7; Ndapewa Hamunime, MD8; Simon Agolory, MD9; 
Gram Mutandi, MBChB9; Naemi N. Shoopala, MPH9; Souleymane Sawadogo, MSc9; Andrew L. Baughman, PhD9; Adebobola Bashorun, MD10; 
Ibrahim Dalhatu, MD11; Mahesh Swaminathan, MD11; Dennis Onotu, MD11; Solomon Odafe, MD11; Oseni Omomo Abiri, MPH11; Henry H. 
Debem11; Hank Tomlinson, PhD11; Velephi Okello, MD12; Peter Preko, MD13; Trong Ao, ScD14; Caroline Ryan, MD14; George Bicego, PhD1; Peter 
Ehrenkranz, MD15; Harrison Kamiru, DrPH16; Harriet Nuwagaba-Biribonwoha, MBChB16; Gideon Kwesigabo, MD17; Angela A. Ramadhani, MD18; 
Kahemele Ng’wangu, MD19; Patrick Swai, MD20; Mohamed Mfaume, MD21; Ramadhani Gongo, MD21; Deborah Carpenter, MD21; Timothy D. 
Mastro, MD22; Carol Hamilton, MD22; Julie Denison, PhD23; Fred Wabwire-Mangen, MD24; Olivier Koole, MD25; Kwasi Torpey, PhD26; Seymour 
G. Williams, MD27; Robert Colebunders, MD25; Julius N. Kalamya, MD28; Alice Namale, MD28; Michelle R. Adler, MD28; Bridget Mugisa, MD29; 
Sundeep Gupta, MD29; Sharon Tsui, MPH23; Eric van Praag, MD30; Duc B. Nguyen, MD31; Sheryl Lyss, MD31; Yen Le, MD31; Abu S. Abdul-
Quader, PhD31; Nhan T. Do, MD32; Modest Mulenga, MD33; Sebastian Hachizovu, MBChB33; Owen Mugurungi, MD34; Beth A. Tippett Barr, 
DrPH35; Elizabeth Gonese, MPH35; Tsitsi Mutasa-Apollo, MBChB34; Shirish Balachandra, MD35; Stephanie Behel, PhD1; Trista Bingham, PhD1; 
Duncan Mackellar, DrPH1; David Lowrance, MD21; Tedd V. Ellerbrock, MD1
Monitoring prevalence of advanced human immunodeficiency Organization (WHO)–recommended “treat-all” guidelines and 
virus (HIV) disease (i.e., CD4+ T-cell count <200 cells/µL) among strategies to facilitate earlier HIV testing and treatment are 
persons starting antiretroviral therapy (ART) is important to needed to reduce HIV-related mortality and HIV incidence.
understand ART program outcomes, inform HIV preven- Data from 10 countries that requested and received support 
tion strategy, and forecast need for adjunctive therapies.*,†,§ for ART program evaluations through CDC and agreed to 
To assess trends in prevalence of advanced disease at ART participate in the analysis were included. Three approaches 
initiation in 10 high-burden countries during 2004–2015, to sampling and analysis were employed (Table 1). In Haiti, 
records of 694,138 ART enrollees aged ≥15 years from 797 Mozambique, and Namibia, where large, centralized, electronic 
ART facilities were analyzed. Availability of national electronic ART patient monitoring systems are employed, all available 
medical record systems allowed up-to-date evaluation of data from 2004–2015 were analyzed. In each of these countries, 
trends in Haiti (2004–2015), Mozambique (2004–2014), and 77%–100% of all ART patients and 67%–100% of all ART 
Namibia (2004–2012), where prevalence of advanced disease facilities were captured in the electronic system. In Nigeria, 
at ART initiation declined from 75% to 34% (p<0.001), 73% Swaziland, Vietnam, and Zimbabwe, nationally representative 
to 37% (p<0.001), and 80% to 41% (p<0.001), respectively. samples of ART facilities were selected, with probability of 
Significant declines in prevalence of advanced disease during selection proportional to facility size. In Tanzania, Uganda, 
2004–2011 were observed in Nigeria, Swaziland, Uganda, and Zambia, investigators purposively selected health facili-
Vietnam, and Zimbabwe. The encouraging declines in preva- ties to represent the range of ART facilities in each country 
lence of advanced disease at ART enrollment are likely due to and ensure that the study remained feasible. Among the seven 
scale-up of testing and treatment services and ART-eligibility sample-based surveys, a sample frame of study-eligible ART 
guidelines encouraging earlier ART initiation. However, in patients was created at each selected facility, and simple random 
2015, approximately a third of new ART patients still initi- sampling was used to select the sample of records. Eligibility 
ated ART with advanced HIV disease. To reduce prevalence of criteria included initiation of ART ≥6 months before data 
advanced disease at ART initiation, adoption of World Health abstraction, during 2004–2015, and at age ≥15 years. Data 
were abstracted from ART records onto standardized abstrac-
* World Health Organization. Guidelines on co-trimoxazole prophylaxis for 
HIV-related infections among children, adolescents and adults. http://www. tion forms by trained study personnel. Because of variations 
who.int/hiv/pub/guidelines/ctx/en/. in the timing of retrospective data collection for the 10 studies 
† Wor ld  Hea l th  Organiza t ion .  The  use  o f  l a t e ra l  f low ur ine (Table 1), the calendar years of ART initiation included in the 
lipoarabinomannan assay (LF-LAM) for the diagnosis and screening of 
active tuberculosis in people living with HIV. http://apps.who.int/iris/ analysis varied among the countries.
bitstream/10665/193633/1/9789241509633_eng.pdf?ua=1&ua=1. The CD4+ T-cell count (CD4) measured in the 6 months 
§ World Health Organization. Rapid advice: diagnosis, prevention and management 
of cryptococcal disease in HIV-infected adults, adolescents and children. http:// before ART initiation and closest to the date of ART ini-
apps.who.int/iris/bitstream/10665/44786/1/9789241502979_eng.pdf. tiation was considered the baseline CD4. For each of the 10 
558 MMWR / June 2, 2017 / Vol. 66 / No. 21 US Department of Health and Human Services/Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report
TABLE 1. Summary of study designs to assess trends in prevalence of advanced disease at antiretroviral therapy enrollment — 10 countries, 
2004–2015
Stage 1: selection of study sites
Estimated no. Estimated no. 
Estimated no. adult ART study-eligible adult 
ART clinics enrollees at No. eligible ART enrollees at Site sampling 
Region Country (yr. of assessment) ART clinics clinics* eligible clinics technique No. clinics selected
Southern Africa Mozambique 379 (2014) 582,000 254 446,379 Census 254
Namibia 213 (2014) 165,468 213 165,468 Census 213
Swaziland 31 (2009) 50,767 31 50,767 PPS 16
Zimbabwe 104 (2008) 103,806 70 93,811 PPS 40
Zambia 322 (2007) 65,383 129 58,845 Purposive 6
East Africa Tanzania 210 (2007) 41,920 85 37,728 Purposive 6
Uganda 286 (2007) 45,946 114 41,351 Purposive 6
West Africa Nigeria†† 178 (2009) 168,335 139 167,438 PPS 35
Caribbean Haiti 200 (2015) 65,000 191 60,705 Census 191
Southeast Asia Vietnam 173 (2009) 28,090 120 25,000 PPS 30
Total — 2,096 1,316,715 1,346 1,147,492 — 797
Stage 2: selection of study patients
Age-eligibility ART enrollment Patient sampling No. eligible 
criteria (age at ART years covered technique at Planned medical records Date of data 
Region Country initiation) (yrs) by analysis selected clinics sample size* analyzed collection
Southern Africa Mozambique ≥15 2004–2013 Census 446,379 446,379 Dec 2014
Namibia ≥15 2004–2012 Census 165,468 165,468 Dec 2013
Swaziland ≥15 2004–2010 SRS 2,500 2,510 Nov 2011–Feb 2012
Zimbabwe ≥15 2007–2009 SRS 4,000 3,896† Jan–Jun 2010
Zambia ≥18 2004–2009 SRS 1,500 1,214§ Apr–Jul 2010
East Africa Tanzania ≥18 2004–2009 SRS 1,500 1,421¶ Apr–Jul 2010
Uganda ≥18 2004–2009 SRS 1,500 1,466** Apr–Jul 2010
West Africa Nigeria†† ≥15 2004–2011 SRS 3,500 3,496 Dec 2012–Aug 2013
Caribbean Haiti ≥15 2004–2015 Census 60,705 60,705 Jun 2016
Southeast Asia Vietnam ≥15 2005–2009 SRS 7,587 7,583§§ Jan–Jun 2010
Total — — — — 694,639 694,138 —
Abbreviations: ART = antiretroviral therapy; PPS = probability of selection proportional to size; SRS = simple random sampling.
 * To keep sample-based studies feasible, in Zimbabwe, Nigeria, and Vietnam, only facilities with ≥50 adults on ART were eligible for sampling, whereas in Zambia, 
Uganda, and Tanzania, only facilities that had enrolled ≥300 adults on ART were eligible.
 † In Zimbabwe, 23 of 3,919 selected patients with either missing gender (n = 12), or missing outcome (n = 11) were excluded from analysis.
 § In Zambia, among 1,457 records sampled, 243 were excluded because of noncompliance with simple random sampling procedures at one site.
 ¶ In Tanzania, among 1,458 records sampled, one patient was excluded because of absence of age data at ART initiation, and 36 patients enrolled in 2004 were 
excluded because of small sample size for 2004.
 ** In Uganda, among 1,472 records sampled, six patients were excluded because of absence of age data at ART initiation.
 †† In Nigeria, implicit stratification was used in the sampling approach.
 ¶¶ In Vietnam, among 7,587 records sampled, four observations were excluded because information on gender was missing.
countries and for each calendar year, the percentages of adult missing baseline CD4 ranged from 9% in Swaziland to 
patients with baseline CD4 <100, <200, and <350 cells/µL 53% in Zimbabwe. In the three countries providing more 
are described with percentages and 95% confidence intervals recent national electronic medical record data, prevalence 
accounting for survey design. Bivariate logistic regression of advanced disease at ART initiation declined from 73% to 
models accounting for survey design were used to evaluate 37% during 2004–2014 in Mozambique, from 80% to 41% 
statistical significance of changes in percentages over calendar during 2004–2012 in Namibia, and from 75% to 34% during 
years, with the likelihood ratio test used to assess departure 2004–2015 in Haiti (Table 2) (supplemental figure; https://
from linear trend over time. Trends in median baseline CD4 stacks.cdc.gov/view/cdc/45821). In addition, over the same 
at ART initiation over time are described, and a linear regres- periods, prevalence of CD4 <100/µL declined from 39% to 
sion model, accounting for survey design, was used to assess 18% in Mozambique, from 39% to 16% in Namibia, and 
statistical significance of changes. from 49% to 20% in Haiti. Prevalence of CD4 <350/µL at 
Across the 10 countries, 694,138 adult ART patient records ART initiation also declined over time in all three countries. 
were analyzed from 797 ART facilities (Table 1). The overall Over the same periods, significant increases in median CD4 
percentage of new ART enrollees during 2004–2015 with count at ART initiation were observed in Mozambique (from 
US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / June 2, 2017 / Vol. 66 / No. 21 559
Morbidity and Mortality Weekly Report 
TABLE 2. CD4 distribution among adult antiretroviral therapy enrollees, by calendar year of ART initiation — 10 countries, 2004–2015
Overall Year (%)
CD4 % 
Country distribution No. Total No. (95% CI) 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 p-value*
Southern Africa CD4<100 66,183 282,129 23 (23–24) 39 39 34 31 29 29 28 25 21 18 18 — <0.001
Mozambique CD4<200 138,453 282,129 49 (49–49) 73 71 68 65 63 62 58 53 44 38 37 — <0.001
CD4<350 233,344 282,129 83 (83–83) 93 90 91 91 90 91 90 89 85 73 71 — <0.001
Missing 164,250 446,379 37 42 33 31 30 31 32 32 30 32 39 50 — —
Namibia CD4<100 16,724 82,774 20 (20–20) 39 35 29 26 26 22 17 13 16 — — — <0.001
CD4<200 48,555 82,774 59 (58–59) 80 76 76 75 76 71 58 36 41 — — — <0.001
CD4<350 77,351 82,774 93 (93–94) 97 95 95 95 95 95 95 91 91 — — — <0.001
Missing 82,694 165,468 50 72 78 79 76 42 38 37 34 30 — — — —
Swaziland CD4<100 770 2,296 34 (31–36) 32 50 44 41 39 36 24 — — — — — 0.035
CD4<200 1,550 2,296 67 (63–71) 72 87 86 78 77 69 54 — — — — — 0.028
CD4<350 2,168 2,296 95 (93–96) 90 98 98 95 97 95 92 — — — — — 0.592
Missing 214 2,510 9 33 15 18 5 8 10 5 — — — — — —
Zambia CD4<100 310 849 36 (33–40) 23 36 37 38 33 35 — — — — — — 0.792
CD4<200 601 849 70 (67–74) 77 73 76 67 69 65 — — — — — — 0.287
CD4<350 810 849 96 (94–97) 100 93 95 96 96 95 — — — — — — 0.562
Missing 365 1,214 30 73 57 32 23 16 16 — — — — — — —
Zimbabwe CD4<100 757 1,820 42 (39–45) — — — 46 40 40 — — — — — — 0.092
CD4<200 1,424 1,820 78 (74–81) — — — 84 75% 75 — — — — — — 0.042
CD4<350 1,767 1,820 97 (95–98) — — — 97 97% 97 — — — — — — 0.756
Missing 2,076 3,896 53 — — — 55 50% 55 — — — — — — —
East Africa CD4<100 432 1,085 41 (37–44) — 40 50 40 41% 37 — — — — — — 0.581
Tanzania CD4<200 804 1,085 77 (74–80) — 77 80 79 77% 77 — — — — — — 0.994
CD4<350 1039 1,085 97 (95–98) — 94 99 97 95% 99 — — — — — — 0.132
Missing 336 1,421 24 — 24 28 22 23% 22 — — — — — — —
Uganda CD4<100 438 1,166 36 (33–39) 54 50 49 30 30 28 — — — — — — <0.001†
CD4<200 859 1,166 74 (71–76) 89 85 83 78 67 60 — — — — — — <0.001†
CD4<350 1,127 1,166 96 (95–97) 99 96 99 95 99 95 — — — — — — 0.122
Missing 300 1,466 20 31 27 23 20 17 16 — — — — — — —
West Africa CD4<100 884 2,876 31 (27–34) 9 36 40 31 31 32 29 25 — — — — 0.001§
Nigeria CD4<200 1,792 2,876 63 (59–67) 68 67 77 65 63 66 60 53 — — — — 0.043§
CD4<350 2,666 2,876 93 (91–94) 96 91 94 92 94 93 92 92 — — — — 0.576
Missing 620 3,496 18 33 21 20 21 18 13 16 20 — — — — —
Caribbean Haiti CD4<100 10,835 47,209 23 (23–23) 49 51 42 32 26 21 23 22 21 19 18 20 <0.001
CD4<200 20,578 47,209 44 (43–44) 75 79 77 68 55 46 46 42 39 36 32 34 <0.001
CD4<350 35,306 47,209 75 (74–75) 92 94 94 90 84 86 83 76 72 70 60 59 <0.001
Missing 25,837 60,705 43 24 36 37 33 37 30 35 31 31 32 33 53 —
Southeast Asia CD4<100 3,015 5,228 58 (55–60) — 74 63 58 59 52 — — — — — — 0.007
Vietnam CD4<200 4,384 5,228 84 (81–86) — 91 87 84 86 80 — — — — — — 0.046
CD4<350 5,038 5,228 96 (95–97) — 98 97 95 97 96 — — — — — — 0.533
Missing 2,355 7,583 31 — 39 42 36 28 25 — — — — — — —
Abbreviations: ART = antiretroviral therapy; CD4 = CD4+ T-cell count (cells/µL); CI = confidence interval.
* P-value derived from logistic regression, accounting for survey design, comparing the percentage of enrollees below the specified CD4 threshold in the most recent 
calendar year with the corresponding percentage in the earliest calendar year with data available.
† Specified p-values were derived from logistic regression including calendar year of ART initiation as a continuous variable because of observed linear trend.
§ In Nigeria, the p-value compares percentages in 2006 with percentages in 2011, to best capture recent declines in prevalence of advanced disease.
128/µL to 261/µL; p<0.001), in Namibia (from 125/µL to (p<0.001), 89/µL to 170/µL (p<0.001), and 22/µL to 92/µL 
230/µL; p<0.001), and in Haiti (from 103/µL to 297/µL; (p = 0.014), respectively, were observed (Figure).
p<0.001) (Figure).
In the seven countries with less recent data, statistically Discussion
significant declines in prevalence of advanced disease were This analysis of 694,138 medical records from 10 low- and 
observed in five countries (Table 2). Prevalence of advanced middle-income countries (LMIC), contributes several find-
disease at ART initiation declined from 72% to 54% in ings relevant for ART programs in resource-limited settings. 
Swaziland (2004–2010), from 84% to 75% in Zimbabwe Observed declines in the prevalence of advanced disease at 
(2007–2009), from 89% to 60% in Uganda (2004–2009), ART initiation in eight countries and increases in median 
from 68% to 53% in Nigeria (2004–2011), and from 91% to baseline CD4 at ART initiation in six countries are likely 
80% in Vietnam (2005–2009) (Table 2) (supplemental figure; due to increasing access to HIV testing and treatment (e.g., 
https://stacks.cdc.gov/view/cdc/45821). Over the same periods increasing numbers of facilities providing testing and treatment 
in Swaziland, Uganda, and Vietnam, statistically significant services), and increasingly inclusive ART eligibility guidelines 
increases in median baseline CD4 from 143/µL to 184/µL (1). Despite this encouraging progress, however, a significant 
560 MMWR / June 2, 2017 / Vol. 66 / No. 21 US Department of Health and Human Services/Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report
FIGURE. Trends in median CD4+ T-cell count at antiretroviral therapy (ART) initiation — 10 countries, 2004–2015
350
300
250
200
Tanzania
150 Mozambique
Swaziland
Zambia
Uganda
100 Zimbabwe
Nigeria
Haiti
50 Vietnam
Namibia
0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Calendar year of ART initiation 
percentage of ART enrollees still started ART with advanced for all persons living with HIV could improve ART program 
disease in recent years. In Haiti, which provided the most outcomes and HIV prevention impact (4,5). For example, in 
recent data on ART enrollees for this analysis (2015), and the Strategic Timing of Antiretroviral Therapy (START) trial, 
which historically has had higher than average median CD4 initiating ART for patients with CD4 >500/µL rather than 
at ART initiation compared with other LMIC (Table 2) (2,3), deferring ART initiation until more advanced disease stages, 
the percentage of ART enrollees with CD4 <200/µL was 34% was shown to reduce risk for a composite endpoint of any 
in 2015. Similarly, in Mozambique in 2014, 37% of patients serious acquired immunodeficiency syndrome (AIDS)–related 
started ART with advanced disease. Although recent data event, non-AIDS–related event, or death by 57% (5). In addi-
from the 10 countries are limited, these data and data from tion, early rather than deferred ART for HIV-positive persons 
a recent meta-analysis, which reported mean CD4 count at in a serodiscordant relationship was found to reduce HIV 
ART initiation for 27 LMIC in 2011–2013 of 186 cells/µL transmission to the HIV-negative partner by approximately 
(3), suggest at least a third of ART patients in LMIC initiated 96% (4). Among the 10 countries studied, “treat-all” guidelines 
ART with advanced disease in 2015. To reduce prevalence have been adopted nationwide in nine (Haiti, Mozambique, 
of advanced disease at ART initiation in LMIC, continued Namibia, Nigeria, Swaziland, Tanzania, Uganda, Zambia, and 
attention to programmatic strategies facilitating earlier HIV Zimbabwe), whereas Vietnam is beginning to phase in “treat-
testing and linkage to care are needed, in addition to adoption all” guidelines with nationwide adoption planned by 2020.
of WHO-recommended universal ART eligibility (“treat-all”) Given the low median baseline CD4 from Vietnam in 
guidelines for persons living with HIV (3), which stipulate that 2009 (92/µL), much lower than Haiti’s median baseline CD4 
all patients become eligible for ART on the day of HIV diag- the same year (219/µL), evaluation of more recent trends in 
nosis, regardless of CD4 count at HIV diagnosis. Early ART baseline CD4 is warranted. With Vietnam’s epidemic largely 
US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / June 2, 2017 / Vol. 66 / No. 21 561
Median baseline CD4 count at ART initiation (cells/µL)
Morbidity and Mortality Weekly Report 
involving men who inject drugs, late presentation for ART 
might be partly explained by suboptimal health-seeking Summary
behavior in this population (6). In Vietnam and similar What is already known about this topic?
LMIC, continued monitoring of the prevalence of advanced Monitoring prevalence of advanced human immunodeficiency 
HIV disease at ART initiation is necessary to inform under- virus (HIV) disease (i.e., CD4+ T-cell count <200 cells/µL) among persons initiating antiretroviral therapy (ART) is important to 
standing of ART program access, outcomes, and prevention help understand ART program outcomes, inform HIV prevention 
strategies (because baseline CD4 gives an indication of how strategies, and forecast need for adjunctive therapies.
long ART enrollees have lived with an unsuppressed viral load). What is added by this report?
Comparing prevalence of advanced disease at ART initiation In an analysis of 694,138 adult ART records from 10 countries, 
among demographic groups (e.g., nonpregnant females, preg- the prevalence of advanced disease at ART initiation during 
nant females, and males) or among more affected population 2004–2015 declined in eight countries. In Mozambique 
groups (e.g., sex workers and persons who inject drugs) can (2004–2014), Namibia (2004–2012), and Haiti (2004–2015), 
inform which populations are being reached late and therefore prevalence of advanced disease at ART initiation declined from 
require targeted interventions (1). 73% to 37% (p<0.001), 80% to 41% (p<0.001), and 75% to 34% (p<0.001), respectively. In the remaining seven countries with 
Recent WHO guidelines recommend a differentiated data available for 2004–2011, significant declines in prevalence 
approach to treatment of persons living with HIV.¶ This of advanced disease were observed in Nigeria, Swaziland, 
approach means that patients initiating ART with advanced Uganda, Vietnam, and Zimbabwe.
HIV disease require additional specialized care to ensure What are the implications for public health practice?
optimal outcomes. For example, tuberculosis (TB) is common Declines in the prevalence of advanced disease at ART enroll-
among patients starting ART with advanced HIV disease, and ment over time in most countries are encouraging, but in 2015, 
remains the most common cause of death, accounting for approximately a third of new ART patients still initiated ART late. 
approximately 40% of deaths, half of which are undiagnosed Adoption of World Health Organization–recommended 
before death (7). Based on recent evidence from a random- “treat-all” guidelines and strategies to facilitate earlier HIV testing, and treatment are needed. These strategies would help 
ized trial (8), WHO recommends that the lateral flow urine reduce HIV-related mortality and HIV incidence.
lipoarabinomannan assay may be used to assist in the rapid 
diagnosis and treatment of disseminated TB among persons 
living with HIV admitted to hospital with CD4 <100/µL and The findings in this report are subject to at least three limi-
symptoms of TB. WHO conditionally recommends the same tations. First, cohort data varied in size and generalizability; 
screening approach for adult outpatients. Early identifica- statistical significance of trends in baseline CD4 over time is 
tion and treatment of disseminated TB can reduce all-cause more likely with larger sample sizes and more calendar years 
mortality (8). In addition, plasma screening for cryptococ- of available data. Second, missing data on CD4 at ART initia-
cal antigen (CrAg) among patients with CD4 <100/µL and tion might have introduced measurement error for summary 
consideration of preemptive treatment with fluconazole for estimates. Third, in several countries, data on more recent 
CrAg-positive patients might reduce 12-month ART mortal- ART enrollees are needed to inform estimates of the current 
ity (9). Co-trimoxazole prophylaxis for ART enrollees with prevalence of advanced HIV disease at ART initiation.
CD4 <350/µL has been shown to reduce mortality (10). Use Encouraging reductions in the prevalence of advanced disease 
of these adjunctive therapies could help reduce relatively high at ART initiation were observed in eight of the 10 countries 
12-month mortality among people taking ART in LMIC (1). studied. This reflects the rapid scale-up of HIV testing and 
Given the importance of baseline CD4 in determining eligi- treatment services in LMIC since 2004 and evolution of HIV 
bility for adjunctive therapies that have the potential to reduce treatment guidelines encouraging earlier ART initiation. 
mortality, it is concerning that 40% of the 694,138 medical However, an estimated one third of new ART enrollees in 
records reviewed lacked documentation of the baseline CD4, LMIC in 2015 started ART with advanced disease, indicating 
with country-specific rates ranging from 9% in Swaziland to that continued scale-up of interventions to facilitate earlier 
53% in Zimbabwe. Quality improvement measures to ensure testing and treatment are needed. For those ART enrollees 
availability of baseline CD4 data for clinical decision-making who do initiate ART late (3), ensuring availability of WHO-
are warranted. recommended adjunctive therapies could help reduce morbid-ity and mortality during ART.
¶ World Health Organization. Guideline on when to start antiretroviral therapy 
and on preexposure prophylaxis for HIV. http://www.who.int/hiv/pub/
guidelines/earlyrelease-arv/en/.
562 MMWR / June 2, 2017 / Vol. 66 / No. 21 US Department of Health and Human Services/Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report
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