Question
My clinic wants to change viral load and CD4 monitoring – aren't both tests needed?
24 September 2007. Related: All topics, CD4 and viral load, Living with HIV long-term.
Hello
My clinic is changing procedures (cost-cutting) to only test for:
* CD4 if you are not on treatment OR
* Viral Load if you are on treatment.
Not to ‘question the experts’, but I was under the impression that a full picture is needed, as the decision of when to start treatment includes a balance of all three results (CD4, Viral Load and Percentage). Is it not possible to have a steady CD4 but rising Viral Load? Or vice versa? Isn’t it important to have a full picture of a situation?
I am considering changing my clinic because of this new procedure, but I am concerned that every clinic is going to move toward doing this.
Answer
Hi
Thanks for your question, which I know is shared by other patients at clinics that are trying to reduce the use of some tests.
The changes are likely to based on looking at results over several years in a group of several thousand patient followed at the Royal Free Hospital, and with the pressure on NHS budgets, you are right that this is driven by cost savings.
It is worth checking whether the changes are really this drastic. Some of the clinics changing monitoring, will still run both tests, but just less frequently – ie when being followed by CD4 count, you may still have viral load, but perhaps only once a year.
However, the choice of 3-monthly tests is itself fairly arbitrary. People who are more ill, have always seen their doctor, and been tested, more frequently – and this will still be the case.
People who are well on stable treatment, in recent years, have generally been going less often, as they realise that the response to treatment is stable and long-term.
You are right that getting a full picture from both tests is important.
However, people on stable long-term treatment (undetectable viral load), with a good CD4 count (over 350) very rarely have any significant change in CD4 count. Viral load rarely changes either – but viral load is the key early marker to whether treatment is still working. This will always increase first, and long before any change in CD4 count.
For people not on treatment, CD4 count is the most accurate and important marker. Although viral load is an independent risk factor for HIV progressing, it is only generally becomes significant as CD4 counts drop below 350, and I’d imagine your clinic would at that point be using both CD4 count and viral load to guide the exact time for starting treatment.
I know that the Bloomsbury clinic is introducing a similar policy to the one you describe, and this was discussed at the UK CAB (Community Advisory Board) in July. Slides and a report from that meeting are online here.
The money saved from ‘unnecessary tests’ is sufficient for two nursing posts.
At that centre, they say that people who want more frequent tests will still be able to get them. If you have been on treatment for a few years now, you may also want to track your results and see if they fit the strong pattern above.
If these results are good, then in some ways it is a good thing that you need less frequent monitoring.
However, I’m not sure whether other clinics will follow. Some doctors think that seeing their patients every 3 months has more difficult to measure benefits, in terms of picking up new problems, even in a small group of patients, that is more important than the costs saved from the tests.
It is kinda pointless if you are stable to go to clinic 8 times a year to wait and give 12 tubes of blood and wait however long to see a doc to be told in 2 mins everything is ok.
I think the key word is stable. And whether or not you are approaching a point where treatment is on the cards, or have just started treatment. Or if you are having symptoms.
I know people at the Bloomsbury clinic who have been watched closely when their CD4 goes below 300, and very closely in the 6 months after starting treatment.
But for people like me who have had a CD4 count of over 300 and an undetectable viral load (under 50) for 3 years now, going 2 or 3 times a year and just seeing the nurse suits me fine.
If I got ill or felt something was wrong I would insist on both tests. I think monitoring has become more routine, but not THAT inflexible at Bloomsbury, and with good reason.
Also, arguably, long term, for people on treatment, tests for kidney and liver function, bone density and heart problems etc are important, and these are now routine. So while the extra CD4 tests could be a loss, other tests important for long term monitoring have been added.
A friend who was not on treatment but feeling tired all the time was offered a CD4 count and viral load every time he went to Bloomsbury, which is every 4 months. Docs seem to have a flexible attitude, and I expect a heartfelt ask will secure both tests.
From what Dr Edwards said at the UK CAB meeting, the new protocol must be acceptable to the individual patient. I can see a CD4 and viral load gives piece of mind. Maybe because I am long in the tooth and doing well on treatment I am less anxious. I remember before starting treatment I was very anxious about how I was doing on my CD4 and viral load.
– matt