Point-of-Care CD4 Testing in Resource-Limited Settings

Is CD4 Testing Outside of the Laboratory Ready for Prime Time?

Shahin Lockman, MD, MS

Disclosures

October 03, 2012

In This Article

Does Point-of-Care CD4 Testing Improve Patient Retention in Care?

CD4 testing is central to assessing the degree of immunosuppression and particularly in establishing eligibility for and urgency of ART initiation. However, many patients in resource-limited settings are lost to care after HIV diagnosis but before receiving their CD4 results. As summarized in a systematic review by Rosen and colleagues,[3] only about one half of persons who test positive for HIV in various care programs in Africa had documentation of CD4 testing and receipt of results, and less than 20% of persons were retained from a positive HIV test through disease staging and ART initiation (if eligible).

In the face of these concerning findings, point-of-care CD4 testing is one of the few interventions that has been demonstrated to increase retention in care and rates of ART initiation among treatment-eligible patients.[4,5,6,7] Faal and colleagues[4] randomly assigned newly diagnosed persons with HIV in South Africa to receive immediate CD4 results at the time of HIV diagnosis or to return to collect their CD4 test results after 1 week. The likelihood of reporting for ART initiation was greater among persons who were given their results immediately (risk ratio, 2.1; 95% confidence interval, 1.4-3.2) than among those who were asked to return to collect their test results. Furthermore, patients who received their CD4 results immediately reported to pre-ART care significantly faster than did those who were not given their results at the time of HIV diagnosis.

The benefits of immediate CD4 results receipt were also demonstrated in an observational study in Mozambique.[5] After point-of-care CD4 testing was introduced to primary health clinics in a range of settings, the proportion of patients lost to follow-up before receiving their result and being assessed for treatment eligibility decreased from 57% to 21%. Of note, the proportion of patients initiating ART increased from 12% to 22%, and the median time to ART initiation declined from 48 to 20 days, primarily because time to receipt of CD4 results dropped from 32 to 3 days. Of note, point-of-care CD4 testing also seems to increase the proportion of pregnant HIV-infected women appropriately receiving ART, which could help reduce mother-to-child HIV transmission rates by facilitating timely initiation of ART or prophylaxis during pregnancy.[8]

Finally, point-of-care CD4 testing has been deployed successfully in mobile community-based or household settings. In one study of mobile HIV counseling and testing and point-of-care CD4 assessment in South Africa, a significantly higher percentage of persons who had point-of-care CD4 testing reported for their first HIV clinic visit compared with patients not offered point-of-care testing (61% vs 42%; risk difference 18.5%).[6] In another study in South Africa in which home-based HIV counseling and testing, point-of-care CD4 testing, and active referral to HIV prevention and care were provided, 91% of all eligible adult residents consented to HIV testing and 100% also underwent CD4 testing,[7] vs the typical rate of 50%-60% seen in the region.[3] Most important, 3 months after HIV testing, 85% of ART-eligible patients had initiated ART.[7]

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