Are CD4-Cell Counts Still Necessary?
In stable HIV-infected patients, results contributed virtually nothing to medical decision making.
The CD4-cell count has been a pivotal tool in HIV care since the late 1980s, when it first achieved its reputation as a reliable and convenient objective marker of immune deficiency. And now, hard as it may be to believe, we may not need it any more — at least not in the care of stable patients.
To explore this possibility, investigators probed the records of all patients attending a single HIV clinic in Washington, D.C., at any time from September 1998 through December 2011 to identify those with continuous long-term HIV suppression. Among patients with CD4 counts between 200 and 249 cells/mm3 at the start of suppression, risk for a subsequent CD4 dip to <200 cells/mm3 was 25%; among those with counts between 250 and 299, risk was 16%; among those with counts between 300 and 349, risk was 5%; and among those with counts 350, risk was 2%. When patients with an unrelated cause for an alteration in CD4-cell count such as severe infection, chemotherapy, or interferon treatment were excluded from the analysis, not a single patient in any group had a dip in CD4 count below 200 cells/mm3 after 2 years of continuous virologic control.
Comment: These results formalize what most of us have independently realized: For stable patients, the periodic CD4-cell count check is an entirely meaningless ritual. Patients may still follow their "numbers" carefully and fret when the values fall, but physicians generally ignore fluctuations in these highly variable measurements. However, as an editorialist points out, in order to wean ourselves from "this wasteful addiction," we have two sizeable tasks: first, persuading oversight programs to acknowledge that viral load is the only meaningful marker of treatment efficacy, and second, persuading patients of the sizeable benefits of foregoing monitoring, which can be measured in money saved, tubes of blood not drawn, and peace of mind.
Published in Journal Watch HIV/AIDS Clinical Care February 25, 2013
Gale HB et al. Is frequent CD4+ T-lymphocyte count monitoring necessary for persons with counts 300 cells/µL and HIV-1 suppression? Clin Infect Dis 2013 Feb 13; [e-pub ahead of print]. (http://dx.doi.org/10.1093/cid/cit004)
Sax PE. Can we break the habit of routine CD4 monitoring in HIV care? Clin Infect Dis 2013 Feb 13; [e-pub ahead of print]. (http://dx.doi.org/10.1093/cid/cit008)
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