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How Often Do You Measure CD4 Cell Counts?

March 28, 2013

Paul E. Sax, M.D.

Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.

Over in Clinical Infectious Diseases, a recent study pretty much nails the fact that routine measurement of CD4 cell counts in clinically stable patients is an all but useless exercise. As summarized by Abbie Zuger in Journal Watch, here's the key finding:

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.

So I've been singing this tune for a while (large nose-enhancing video here), and as a result have been trying for some time to get my stable patients to reduce the frequency of CD4 monitoring -- or even, as I note in this editorial, give it up entirely!

And has this been a successful effort? For some patients, yes, but for others it's hopeless -- they simply can't understand that this test, which was the cornerstone of HIV monitoring for decades, now provides us with information that has no role in determining what we do therapeutically (provided the viral load remains suppressed).

In short, we order the test for emotional and sentimental reasons only -- it's reassuring to patients to hear that their CD4 cell count is stable, and we've been doing it for so long, why stop now. But are these good enough reasons? Before you answer in the affirmative, remember that unexplained drops in CD4 (which are not uncommon) have the opposite effect, and require frequent education about why the result won't change our patients' treatments.

So I ask you, providers of HIV care, the following burning question:

How often do you measure CD4 cell counts in your stable patients with long-term virologic suppression?

  1. Every 3-4 months.
  2. Every 6 months.
  3. Every year.
  4. Never, if can I get away with it.

[Editor's note: You can vote on this poll and view results by visiting the original blog post.]

Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.

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Journal Watch is a publication of the Massachusetts Medical Society.
 

Reader Comments:

Comment by: will (Florida) Mon., Apr. 22, 2013 at 10:17 pm EDT
I will give you one very GOOD reason to periodically (twice a year) measure CD4 counts.
The CDC still uses 200 T4's as the marker and magic number and qualifier to define FULL BLOWN AIDS from HIV+ asymptomatic. Which is enormous when it comes to SSID/VA/and other program entitlements.
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Comment by: florence (medford) Sat., Apr. 20, 2013 at 1:23 pm EDT
If having your counts checked on a regular basis's helps the mental factor in having the virus.. why would you want to add more stress than just having the virus, knowing what is going on with our counts helps us to deal with what we are going thru in a better way...Those of us who need that comfort it is good for us knowing
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Comment by: jim (boston) Fri., Apr. 5, 2013 at 10:25 am EDT
Testing may not be a matter of medical necessity, but those of us who are receiving help from drug assistance programs are required to have these blood tests done twice a year to keep our benefits.
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Comment by: Dale T. Read (Annapolis, MD) Thu., Apr. 4, 2013 at 8:21 pm EDT
So call me the ignorant patient, but what the heck is wrong with a fully educated doctor and patient when dealing with a deadly disease? I mean in just the 7 years I've been positive the fads or trends have shifted from three indices to a focus on viral load (VL) level only. My first ID doctor was a very detailed person and took the time to explain the value of measuring CD-4 ( one measure of my immune system army if you will..How is my critical infantry fighting soldier level?) ..my viral load..how many of the enemy are coming through my defenses at any given moment, and the then deeply honored percentage ..do I ahve a great balance of infantry solders along with my artillery, my tanks, my infrastructure / engineering corps, etc. The value to me as a patient was mindset. When my doc told me my CD-4 is 900 or 1200, and that my VL while not suppressed to obliviov,, it was level at 7,000 and going nowhere ( up or down)... and my percentage 28, 29, 32 ..This gave me the momentum to be positive in my attitudes. to believe that I was beating this nasty killer enemy. So too as these things got worse, I could track it , and it helped me to accept that I needed to go on meds. when I did. Right, wrong or indifferent from a purely therapeutic /clinical value viewpoint, these tests and measurements give me reason to fight and hope. I like knowing my CD-4, my VL and the percentage that says my CD-4 is OK in the overall make up of fighting soldiers.
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