Background The CD4 cell count or percent (CD4%) at the start of combination antiretroviral therapy (cART) are important prognostic factors in children starting therapy and an important indicator of program performance. We describe trends and determinants of CD4 measures at cART initiation in children from low-, middle- and high-income countries. Methods We included children aged <16 years from clinics participating in a collaborative study spanning sub-Saharan Africa, Asia, Latin America and the United States of America (USA). Missing CD4 values at cART start were estimated through multiple imputation. Severe immunodeficiency was defined according to World Health Organization criteria. Analyses used generalized additive mixed models adjusted for age, country and calendar year. Results 34,706 children from nine low-income, six lower middle-income, four upper middle-income countries and one high-income country (United States of America, USA) were included; 20,624 children (59%) had severe immunodeficiency. In low-income countries the estimated prevalence of children starting cART with severe immunodeficiency declined from 76% in 2004 to 63% in 2010. Corresponding figures for lower middle-income countries were from 77% to 66% and for upper middle-income countries from 75% to 58%. In the USA, the percentage decreased from 42% to 19% during the period 1996 to 2006. In low- and middle-income countries infants and children aged 12-15 years had the highest prevalence of severe immunodeficiency at cART initiation. Conclusions Despite progress in most low- and middle-income countries, many children continue to start cART with severe immunodeficiency. Early diagnosis and treatment of HIV-infected children to prevent morbidity and mortality associated with immunodeficiency must remain a global public health priority.

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Background, objectivesThe diabetes care network ‘Maison du diabète et de la nutrition de Nancy et 54’ (MDN54) is a territorial structure which organises formalised and structured therapeutic patient education (TPE) by a multidisciplinary team for type 2 diabetic patients (T2DM) or obese people, usually not treated by an endocrinologist. The goal of this study was to (1) compare baseline characteristics of the T2DM patients from MDN54 with patients followed in a diabetes university hospital department (CHU), (2) to describe the follow up of those patients during 1 year and (3) to compare the changes of some relevant parameters between the territorial and the hospital structure.Programme: description, implementation, monitoring elementsT2DM patients are registered at MDN54 by their general practitioner. The patients take part to TPE programs according to a formalised programme as recommended by the HAS: educational diagnosis, group sessions and/or individual face-to-face meeting with an educator, assessment of self-management, and more educational sessions if needed. The sessions are conducted by a multidisciplinary team including private nurses, dieticians, physiotherapists, psychologists and chiropodist. All the sessions take place outside the hospital, at the head office of the MDN54 or in other quarters or cities (rooms offered by local authorities). The family physician is responsible for the annual diabetes check up according to the french national guidelines. TPE programmes have been adapted to primary care during training courses for general practitioners organised by the CHU team. This annual monitoring includes relevant clinical characteristics (body mass index, blood pressure, diabetes complications: retinopathy, neuropathy, wound risk level for diabetic feet, …) and biological results (HbA1c, LDL-cholesterol, HDL-cholesterol, triglycerides, creatinine's clearance by MDRD, microproteinuria, etc). The MDN54’s cohort included 486 T2DM patients registered between 2005 and 2008; 243 patients had had a complete initial annual assessment and 100 patients 2 successive annual assessments. CHU's cohort included 1997 patients and among them 848 T2DP with 2 successive annual assessments on the same period. Seventy-five patients of both populations were matched (CHUap and MDN54ap) using the propensity score on the initial values of several parameters (age, sex, duration of diabetes, BMI, total cholesterol, creatinine's clearance, retinopathy, renal failure, neuropathy, wound risk, hypertension, peripheral vascular disease, treatment with insulin).Results in terms of clinical impactInitial age (62.8 vs 63.0 years), BMI (31.7 vs 31.3 kg/m2) and HbA1c (7.53 vs 7.49%) of the two cohorts (MDN54 vs CHU) were similar (p=NS). Diabetes' duration (14.3 vs 9.0 years), rate of retinopathy (28.3 vs 10.4%) and nephropathy (44.9 vs 22.2%) were higher in the CHUs cohort (p<0.001). There was an improvement in HbA1c level for MDN54 patients at 1 year (7.53 vs 7.22%, p<0.001). The 1 year changes in HbA1c were similar in the two matched...