A new study shows that a disproportionate number of people living with HIV—notably women, African Americans and older adults—are presenting for care with low CD4 counts, a troubling concern that hasn’t improved significantly in recent years. The results were published in the June 1 issue of Clinical Infectious Diseases.

Waiting to start antiretroviral therapy until CD4 counts are well below HIV treatment guidelines leads to numerous problems. Not only does this increase the risk that a person will develop an AIDS-related opportunistic infection, but it may also increase his or her risk of developing cardiovascular disease and certain cancers. What’s more, when people wait too long to start ARV treatment, the chances of achieving and maintaining a healthy CD4 cell count are reduced. A number of studies have found that a significant number of people who present late to HIV care did so because they hadn’t been tested for the virus and did not know their status.

To assess when people are entering HIV care, and how this trend has changed over time, Keri Althoff, PhD, MPH, from Johns Hopkins University in Baltimore, and her colleagues analyzed data from a large HIV cohort study called the North American–AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Althoff’s team examined data on 44,491 people with HIV who presented for HIV care for the first time between January 1997 and December 2007.

Althoff and her colleagues found that the average CD4 count upon entering care increased between 1997 and 2007, but only slightly—from 256 to 317. More than half the people in the study, however, should already have been on ARV treatment upon entering care—using the minimum guidelines now in place in most developed nations, which is a CD4 count less than 350. Althoff’s team found that 54 percent of those who first presented for care in 2007 already had a CD4 count that had fallen below 350, compared with 62 percent in 1997.

The greatest gains in getting people into care earlier, according to the study, were seen among Latinos, men who have sex with men, and injection drug users. Heterosexuals, African Americans and older individuals lagged behind.

“These data provide strong evidence that implementation of new strategies for earlier testing and effective linkage into care are urgently needed,” write the study’s authors.

In an accompanying editorial, Cynthia Gay, MD, MPH, an assistant professor of medicine at the University of North Carolina at Chapel Hill, concurs. “Earlier in the epidemic, many predicted that improvements in HIV therapy and outcomes would translate into increased HIV testing, and thus earlier diagnosis and care. The work of [Althoff’s team] and others refutes this,” Gay asserts. “We have to ask why we fail to help more HIV-infected individuals access treatment earlier in their disease course.”