Is it safe to drop CD4 monitoring among virologically suppressed

patients?A cohort evaluation from Khayelitsha,

South Africa

Nathan Ford (1), Kathryn Stinson (2,3), Mary-Ann Davies (3), Vivian Cox (2), Gem Patten (2), Carol Cragg (4), Gilles Van Cutsem (2,3), Andrew Boulle (3)

1. Department of HIV/AIDS, World Health Organization, Geneva, Switzerland2. Médecins Sans Frontières

3. Centre for Infectious Disease Epidemiology and Research, University of Cape Town4. Western Cape Department of Health, Cape Town, South Africa.

Dynamics of CD4 in virally suppressed patients

Hill A, IAS 2013; Gale et al CID 2013

If VL <200 copies/mL and CD4 >300 cells/uL, 97% probability of CD4 >

200 cells/uL for 4 years

Methods

Setting

- Khayelitsha township, Western Cape of South Africa

- High rate of TB/HIV co-infection (67%)

- Prospective ART cohort (11 clinics)

- Routine viral load and CD4 (6 months)

- AZT+3TC+EFV up to 2004; AZT replaced by d4T then TDF

Inclusions

- All adult patients (≥16 years) initiating ART from 2001 to 2012 who achieved VL

<400 copies and CD4>200 cells/μl

- At least one subsequent paired measurement (<1 month)

Population

- 5697 patients, 34 years (IQR 20-40)

- Median baseline CD4: 63 cells/μl (2001) to 225 cells/μl (2012)

Results

>90% of suppressed patients maintained CD4+ cell counts >200 cells/µl up to 10 years

97% (133/137) of CD4 declines <200 cells/µl were transient

Conclusions

• These data are consistent with findings from trial and observational studies in Western settings that CD4 measures rarely change in virologically suppressed patients

• CD4 remains a critical diagnostic tool for risk stratification and ART and prophylaxis decisions

• In settings where both CD4 and viral load are available, countries could consider reducing or eliminating CD4 for monitoring