Limiting CD4 Count Monitoring Saves Money Without Compromising HIV Patients' Health

Frequent CD4 cell monitoring is unnecessary in well-controlled HIV-positive patients, new study results suggest.

The CD4 count is a surrogate marker of disease control and progression, as well as a patient’s risk of opportunistic infections. The 2014 Department of Health and Human Services guidelines state that CD4 counts are optional in patients with CD4 results >500 cells/mL, though they recommend annual testing in patients with stable CD4 counts between 300 cells/mL and 500 cells/mL for at least 2 years.

Reduced monitoring presents a cost-saving opportunity for the US Department of Veterans Affairs (VA) and health care institutions across the nation. An article published ahead-of-print in the journal

Clinical Infectious Diseases

provides evidence that curtailing optional and minimal CD4 monitoring reduces medical spending without impacting quality of care.

The study included VA patients receiving at least 4 HIV-1 RNA tests and 4 CD4 tests in the 5 years before September 30, 2013. The researchers defined viral suppression as an HIV count <200 copies/mL. Patients with viral suppression and a CD4 count >300 cells/mL were eligible for minimal monitoring, and those with a CD4 count ≥500 cells/mL were eligible for optional monitoring.

VA providers decreased CD4 testing by 10.8% between 2009 and 2012, and full guideline implementation would have resulted in a reduction of an additional 28.9%.

The researchers found that 35.4% of patients were eligible for reduced monitoring using the strict definition included in the guidelines. Guideline-based monitoring would save the VA $600,000 per year in direct testing supplies costs.

Savings for the entire US health sector would likely be far greater than the $10 million that researchers from Massachusetts General Hospital estimated in 2013. However, CD4 testing represents <1% of the total cost of HIV care.

A meta-analysis found that only 0.4% of patients with viral suppression had unexplained CD4 counts <200 cells/mL. This study found 1.1% of minimally monitored patients and 0.3% of optionally monitored patients had unexplained low CD4 counts. Reduced monitoring saves money and also reduces patient anxiety related to insignificant changes in results.

The guideline-recommended reduction in CD4 monitoring is a low-risk method to reduce direct medical spending without compromising patient health.