1. Nanina Anderegg, Ole Kirk for the IeDEA & COHERE consortia 24.07.2017
Immunodeficiency at the start of antiretroviral therapy in low-, middle- and high-income countries
Nanina Anderegg, Ole Kirk
for the IeDEA & COHERE consortia

2. No conflicts of interest to declare.
conflict of interest
No conflicts of interest to declare.

3. background

4. background … in an ideal world … in the real world
delayed implementation of guidelines
late presentation / diagnosis
how far off are we in the real world?

5. aim
“Description of temporal trends in the CD4 cell count at initiation of cART in adults in low-, middle- and high-income countries“

6. methods - data routine HIV data from 2 large collaborations: IeDEA
International epidemiology Databases to Evaluate AIDS
7 regions (4 in sub-Saharan Africa, Asia-Pacific, Latin America, North America)
COHERE
Collaboration of Observational HIV Epidemiological Research in Europe

7. methods - analysis adults, cART start 2002 – 2015
multiple imputation of missing CD4 cell counts
aggregation by country, calendar year, sex:
median CD4 cell count
% severe immunodeficiency (< 200 cells/µL)
estimation of time trends of outcomes by income group and sex: weighted (generalized) additive mixed models

8. results - descriptive statistics

9. results - descriptive statistics
LIC
LMIC
UMIC
HIC
Overall
Countries 16 11 9 19 55
Patients
196,143
526,390
81,958
153,424
951,857
Female
64%
63%
60%
25%
57%
Median age (IQR) [years]
35 (29-42)
39 (32-47)
35 (30-43)
Median cART start (IQR)
2010 ( )
2010 ( )
2008 ( )
2010 ( )
CD4 missing
45%
33%
27%
23%

10. results - median CD4 highest increases: UMIC, LIC, LMIC, HIC
larger increase in females (except HIC)
in 2015: <350 cells/µL in all income groups

11. results - severe immunodeficiency
largest decreases: LIC, UMIC, HIC, LMIC
larger decreases in females (except HIC)
2015: still >25% severe immunodeficiency
plateaus (HIC)

12. summary median CD4 cell count at cART start overall increase
2015: < 350 cells/µL in all income groups
severe immunodeficiency at cART start
overall decrease
2015: > 25% severe immunodeficiency in all income groups
plateaus in HIC

13. how far off are we...? … in an ideal world:
Question: how far off are we in the real world?

14. how far off are we...? Question: how far off are we in the real world?
Answer: quite a bit!

15. conclusion
“Substantial additional efforts and resources are needed to increase testing coverage with the aim of achieving earlier diagnosis, linkage to care, and initiation of cART globally”

16. acknowledgements Sponsoring Institutions Regions and PIs Funding
National Institute of Allergy and Infectious Diseases (NIAID)
Carolyn Williams, Melanie Bacon, Robin Huebner, Rosemary McKaig, Gerald Sharp, Lori Zimand
Eunice Kennedy Shriver National Institute for Child Health Development (NICHD)
Rohan Hazra
National Cancer Institute (NCI)
Geraldina Dominguez
National Institute of Mental Health (NIMH)
Pim Brouwers
National Institute on Drug Abuse (NIDA)
Katherine Davenny
Regions and PIs
Asia-Pacific
Annette Sohn (amfAR TREAT Asia)
Matthew Law (University of New South Wales)
CCASAnet
Cathy McGowan (Vanderbilt University)
Pedro Cahn (Fundación Huésped, Argentina)
Central Africa
Kathryn Anastos (Albert Einstein College of Medicine)
Denis Nash (CUNY School of Public Health)
East Africa
Kara Wools-Kaloustian (Indiana University)
Constantin Yiannoutsos (Indiana University)
NA-ACCORD
Richard Moore (Johns Hopkins University)
Southern Africa
Matthias Egger (University of Bern)
Mary-Ann Davies (University of Cape Town)
West Africa
Francois Dabis (ISPED)
Funding
The International Epidemiology Databases to Evaluate AIDS (IeDEA) is supported by the U.S. National Institutes of Health’s National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Cancer Institute, the National Institute of Mental Health, and the National Institute on Drug Abuse: Asia-Pacific, U01AI069907; CCASAnet, U01AI069923; Central Africa, U01AI096299; East Africa, U01AI069911; NA-ACCORD, U01AI069918; Southern Africa, U01AI069924; West Africa, U01AI This work is solely the responsibility of the authors and does not necessarily represent the official views of any of the governments or institutions mentioned above.
Project Working Group
Nanina Anderegg, Klea Panayidou, Matthias Egger, Yao Abo, Kathryn Anastos, Keri Althoff, Eric Balestre, Renaud Becquet, Barbara Castelnuovo, Lara Coelho, Branda Crabtree-Ramirez, Mary-Ann Davies, Nicole De La Mata, Stephany Duda, Aime Freeman, Stephen Gange, Awachana Jiamsakul, Mari Kitahata Matthew Law, Catherine McGowan, Richard Moore, Gertrude Nakigozi, Denis Nash, Oon Tek Ng, Armel Poda, Larry Riggen, Jean d’Amour Sinayobye, Christelle Twizere, Kara Wools-Kaloustian, Marcel Yotebieng.

17. acknowledgements Project leaders and statistical analysis
Juan Berenguer, Julia Bohlius, Vincent Bouteloup, Heiner Bucher, Alessandro Cozzi- Lepri, François Dabis, Antonella d’Arminio Monforte, Mary-Anne Davies, Julia del Amo, Maria Dorrucci, David Dunn, Matthias Egger, Hansjakob Furrer, Marguerite Guiguet, Sophie Grabar, Ali Judd, Ole Kirk, Olivier Lambotte, Valériane Leroy, Sara Lodi, Sophie Matheron, Laurence Meyer, Jose Mª Miró, Amanda Mocroft, Susana Monge, Fumiyo Nakagawa, Roger Paredes, Andrew Phillips, Massimo Puoti, Michael Schomaker, Colette Smit, Jonathan Sterne, Rodolphe Thiebaut, Claire Thorne, Carlo Torti, Marc van der Valk, Linda Wittkop.
Regional Coordinating Centres
Bordeaux RCC: Diana Barger, Christine Schwimmer, Monique Termote, Linda Wittkop; Copenhagen RCC: Maria Campbell, Casper M. Frederiksen, Nina Friis-Møller, Jesper Kjaer, Dorthe Raben, Rikke Salbøl Brandt.
Steering committee
Contributing Cohorts: Ali Judd (AALPHI) Robert Zangerle (AHIVCOS),Giota Touloumi (AMACS), Josiane Warszawski (ANRS CO1 EPF/ANRS CO11 OBSERVATOIRE EPF), Laurence Meyer (ANRS CO2 SEROCO), François Dabis (ANRS CO3 AQUITAINE), Murielle Mary Krause (ANRS CO4 FHDH), Jade Ghosn (ANRS CO6 PRIMO), Catherine Leport (ANRS CO8 COPILOTE), Linda Wittkop (ANRS CO13 HEPAVIH), Peter Reiss (ATHENA), Ferdinand Wit (ATHENA), Maria Prins (CASCADE), Heiner Bucher (CASCADE), Diana Gibb (CHIPS), Gerd Fätkenheuer (Cologne-Bonn), Julia Del Amo (CoRIS), Niels Obel (Danish HIV Cohort), Claire Thorne (ECS), Amanda Mocroft (EuroSIDA), Ole Kirk (EuroSIDA), Christoph Stephan (Frankfurt), Santiago Pérez-Hoyos (GEMES-Haemo), Osamah Hamouda (German ClinSurv), Barbara Bartmeyer (German ClinSurv), Nikoloz Chkhartishvili (Georgian National HIV/AIDS), Antoni Noguera-Julian (CORISPE-cat), Andrea Antinori (ICC), Antonella d’Arminio Monforte (ICONA), Norbert Brockmeyer (KOMPNET), Luis Prieto (Madrid PMTCT Cohort), Pablo Rojo Conejo (CORISPES-Madrid), Antoni Soriano-Arandes (NENEXP), Manuel Battegay (SHCS), Roger Kouyos (SHCS), Cristina Mussini (Modena Cohort), Pat Tookey (NSHPC), Jordi Casabona (PISCIS), Jose M. Miró (PISCIS), Antonella Castagna (San Raffaele), Deborah Konopnick (St. Pierre Cohort), Tessa Goetghebuer (St Pierre Paediatric Cohort), Anders Sönnerborg (Swedish InfCare), Carlo Torti (The Italian Master Cohort), Caroline Sabin (UK CHIC), Ramon Teira (VACH), Myriam Garrido (VACH). David Haerry (European AIDS Treatment Group)
Paediatric cohort representatives: Ali Judd, Pablo Rojo Conejo
European AIDS Treatment Group: David Haerry
Project Working Group
Ole Kirk, Belen Alejos, Andrea Antinori, Barbara Bartmeyer, Antonella Castagna, Geneviève Chêne, Dominique Costagliola, Jeannie Collins, Francois Dabis, Antonella d’Arminio Monforte, Valerie Delpech, Katharina Grabmeier- Pfistershammer, Christian Manzardo, Laurence Meyer, Cristina Mussini, Niels Obel, Nikos Pantazis, Dorthe Raben, Peter Reiss, Caroline Sabin, Anders Sönnerborg, Marcel Stoeckle, Claire Thorne, Carlo Torti, Jan-Christian Wasmuth, Linda Wittkop, Stephane De Wit.
Sources of funding
The COHERE study group has received unrestricted funding from: Agence Nationale de Recherches sur le SIDA et les Hépatites Virales (ANRS), France; HIV Monitoring Foundation, the Netherlands; and the Augustinus Foundation, Denmark. The research leading to these results has received funding from the European Union Seventh Framework Programme (FP7/ ) under EuroCoord grant agreement n° A list of the funders of the participating cohorts can be found on the Regional Coordinating Centre websites at lt.aspx and bordeaux2.fr/cohere."
Executive Committee
Stéphane de Wit (Chair, St. Pierre University Hospital), Jose M. Miró (PISCIS), Dominique Costagliola (FHDH), Antonella d’Arminio- Monforte (ICONA), Antonella Castagna (San Raffaele), Julia del Amo (CoRIS), Amanda Mocroft (EuroSida), Dorthe Raben (Head, Copenhagen Regional Coordinating Centre), Geneviève Chêne (Head, Bordeaux Regional Coordinating Centre)

18. thank you & questions?