Can We Stop Monitoring CD4 Counts Entirely in HIV?

Paul E. Sax, MD


March 03, 2011

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Hi. This is Paul Sax from Brigham and Women's in Harvard Medical School. Today I'd like to give you a radical proposal about patient management -- just something to consider. It's as follows: in a substantial fraction of the patients that we follow, we don't need to measure CD4 counts at all. As you know, the Department of Health and Human Services recently came out with revised guidelines saying that in clinically stable patients, once or twice a year CD4 monitoring was fine.[1] How about getting rid of it entirely? Here's the argument for that.

We all know that patients with very high CD4 counts, who are virologically suppressed, have a lot of variability in the CD4 counts. I'm sure many of you who manage these patients have to explain to patients that their CD4 count could go from 800 to 1000 to 600 to 500 cells/µL. The real clinical importance of that is unknown, and it certainly doesn't change our management. What about the discordant patients? We all have patients in our practice who are virologically suppressed but fail to get a good CD4 response. How about them?

Recently, a paper was published, a very interesting paper looking at the clinical outcomes in those patients.[2] This study was conducted on a cohort in Germany, and showed that although having a low CD4 count despite that virologic suppression had bad prognostic implications, most of the worst prognosis was in the first 6-12 months. Once you got out to 2 years and beyond, patients actually had almost no opportunistic infections, so the prognosis ultimately turns out to be very good, at least from an HIV complications perspective.

The other reason that CD4 monitoring after prolonged virologic suppression really isn't that useful is that we do not, at this point, have any antiviral management strategies that can help address these discordant responders. Aside from some obvious things like avoiding tenofovir plus didanosine, which isn't recommended anyway, or removing drugs that suppress the bone marrow (like AZT [azidothymidine]), there is no antiviral switch strategy, add-on strategy, or intensification strategy that we can use.

That's my radical proposal. Perhaps I'm offering it today because during this brutal winter...we're currently almost going to reach 60° today in Boston. I hope that the weather continues for those of you who are going to join us in Boston for the Retrovirus Conference. The references to the guidelines and the papers will be in the text after this presentation. I'm interested to hear your thoughts as well. Thanks very much.


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