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CD4 cell count monitoring more than
once a year is unnecessary for people doing well on HIV therapy, investigators
from the United States report in the online edition of Clinical Infectious
Diseases. They found that there was a 99% probability over five years that
people whose viral load was suppressed and who had a CD4 cell count above 300
cells/mm3 would maintain a CD4 level adequate to protect them from
opportunistic infections.
“Our data supports less frequent CD4
monitoring in clinically stable, virally suppressed patients and suggests that
routine CD4 monitoring for this population may be unnecessary,” write the
authors.
They believe that reducing the
frequency of CD4 cell testing would have benefits for both providers and
patients, saving substantial sums of money and reducing anxiety in people with
HIV.
The author of an editorial
accompanying the study labelled the current frequency of CD4 cell monitoring in
people undergoing successful HIV therapy a “wasteful addiction”.
CD4 cell counts are used to gauge
the health of the immune system and have long been a central component of HIV
care. Regular monitoring is important for people who are not taking
antiretroviral therapy, and a fall in CD4 cell count to around 350 cells/mm3 is
the threshold for starting antiretroviral therapy in the United Kingdom. (Other
countries have begun to recommend earlier treatment, although expert opinion in
the United States remains divided on when to start treatment in the absence of
data from a large randomised study.)
Current United States treatment
guidelines recommend that people who are doing well on HIV treatment with an
undetectable viral load should have their CD4 cell count monitored every six to
twelve months.
Investigators from the Department of
Veterans Affairs in Washington DC wanted to see if this frequency of monitoring
was clinically justified. They especially wanted to establish the risk of the
CD4 cell count falling to below 200 cells/mm3 – indicating vulnerability to
HIV-related opportunistic infections and the need for prophylaxis – for people
treated with anti-HIV drugs whose viral load was suppressed to below 200
copies/ml.
A total of 832 treated people who
received care between 1998 and 2011 were included in the study. All had paired
CD4 cell and viral load results. The median period of follow-up was 7.7 years
and the median interval between CD4 and viral load monitoring was 113 days.
Overall, 93% of participants
maintained their CD4 cell count above the 200 cell/mm3 threshold during periods
of virological suppression. In 61 participants CD4 cell count dipped below this
level. However, in 24 individuals the cause was unrelated to HIV.
The investigators calculated that
people with CD4 cell counts between 300 and 349 cells/mm3 and virologic
suppression had a 95% probability over four years of maintaining a CD4 cell
count above the 200 cell/mm3 level. When baseline CD4 cell count was above 350
cells/mm3, the probability was 97% and increased to 99% when non-HIV-related
causes of CD4 cell count decline were excluded.
The investigators believe their
results show that frequent, routine monitoring of CD4 cell count in people
undergoing successful HIV treatment is unnecessary, even harmful.
“Reduced CD4 monitoring would
provide a substantial cost saving,” they write. “For example, 55% of our
patients had both viral suppression < 200 and CD4 > 300...if these
patients were monitored only annually, over $41,000 would be saved.” Another
benefit would be “alleviating patient anxiety from fluctuations in serial CD4
due to laboratory and physiologic variability”.
The author of an accompanying
editorial believes that frequent monitoring of CD4 cell count in stable,
treated patients with virologic suppression is unnecessary, with no impact on
“clinical decision making”.
He suggests that care guidelines
should be revised, removing the recommendation for regular CD4 cell count tests
in clinically stable patients. Instead, guidelines should stress the primacy of
viral load monitoring for individuals treated with antiretroviral drugs.
“We would need to continue educating
our patients about why we are changing our practice,” writes the author. “The
message should be simple – we no longer need this test to make decisions about
your treatment.”
Note:
These findings should be discussed with a medical professional familiar with
your medical history before making individual decisions about the frequency of
clinic visits.
The Friends of AIDS Foundation is
dedicated to enhancing the quality of life for HIV positive individuals and
empowering people to make healthy choices to prevent the spread of the HIV
virus. To learn more about The Friends of AIDS Foundation, please visit: http://www.friendsofaids.org.
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