Question
Is it safe for my clinic to reduce – or stop – CD4 monitoring?
29 January 2018. Related: All topics, CD4 and viral load.
Hi, I have be HIV+ and on meds for 8 year and was used to having my CD4 count checked every 3-4 months. Then the clinic moved to doing this every 6 months and now they only want to do this once a year. My doctor said that becasue my count is his (730) the clinic might stop CD4 monitoring altogether. This worries me as it doesn’t sound safe.Every 3
Answer
Hi
Thanks, this is a great question. It can be worrying when the need to test is reduced, especially when many services are being changed to save money.
In this case though, there is good safety evidence to show that once your CD4 count is above 350, and especially if above 500, moving to less frequent monitoring is very safe. This is based on having an undetectable viral load for the last year and having good adherence.
Researchers looked at the results of tens of thousands of CD4 tests and found that nothing significantly changes at these high CD4 levels.
- If your CD4 count is between 200 to 350 cells/mm3, then testing every 3 – 6 months is recommended.
- If your CD4 has been above 350 (confirmed for more than a year), then checking every year is also fine.
- If you have any complications, including new symptoms, then your doctor can go back to testing more frequently. This is also the case if you change treatment.
Most doctors are also very happy to move to testing the CD4 count one a year. This is part of the routine other annual checks.
Even though the UK guidelines say that CD4 counts are not needed after getting a stable CD4 count above 350, most doctors will still want to check your CD4 count every year. This is not an expensive test, and confirming the CD4 count annually is still widely preferred. also, HIV positive people like to know their CD4 count is okay, and so the flexibility to still do this is important.
The UK monitoring guidelines are also not clear about whether CD4 monitoring can be stopped completely. Table 3.5 on page 8 recommends still doing the annual tests in Table 3.2 (ie including the CD4 count). Although only 3% of people with high stable CD4 counts have a significant drop, for these people, the annual test will be important. (See p 33 of UK guidelines).
Of note, US guidelines make similar recommendations. They say that in someone who has been on stable ART for more than two years, CD4 tests are recommended once a year if the CD4 count is between 300 and 500 cells/mm3. For people with a count above 500 cells/mm3, CD4 testing is optional. In practice, this probably means every 1-2 years.
UK BHIVA monitoring guidelines, 2016: (see Tables on p7-8).
http://www.bhiva.org/monitoring-guidelines.aspx
US HIV adult guidelines, 2017: (see Table 3, C-3).
https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/0
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