A Systematic Review and Meta-regression of Temporal Trends in Adult CD4+ Cell Count at Presentation to HIV Care, 1992-2011

Background. The clinical status of human immunodeficiency virus (HIV)-positive persons at the time of presentation to medical care has important individual-and population-level implications. Methods. We synthesized the literature on clinical status of adults newly presenting to care for HIV infection in developed countries to generate an estimate of the time trend for CD4 cell count at the initiation of HIV care. We systematically searched PubMed for studies published between January 2000 and November 2011 to identify those that reported CD4 cell count for patients newly presenting to HIV care according to standardized inclusion criteria. We abstracted the mean or median CD4 cell count or reconstructed the mean CD4 cell count from the presented data describing the number or proportion of patients in CD4 cell count categories. We estimated the change in CD4 cell count over time by modeling it as a weighted linear function of calendar year. Results. Based on a meta-regression of 197 point estimates encompassing CD4 cell count measurements from 169 007 patients in 44 studies, mean CD4 cell count at presentation increased minimally by 1.5 cells/mu L per year (95% CI, -6.1 to 5.5 cells/mu L per year), from 307 cells/mu L in 1992 to 336 cells/mu L in 2011. Conclusions. In developed countries, patients' CD4 cell counts at first presentation to medical care have not increased meaningfully over the past 20 years. New and innovative strategies are imperative to identify persons earlier in the course of their infection and link them promptly with medical care.