People who test positive for HIV should undergo CD4 testing
CD4 testing is recommended by health care practitioners
Limited testing equipment
Limited public access to testing
Lack of domestic funding
Among the suggestions to improve the implementation of WHO guidelines, respondents mentioned building diagnostic capacity, including with equipment and services, and creating demand among patients and health care workers.
“The lack of funding for infrastructure and capacity building of health care providers is one of the reasons to reach out to all people living with HIV,” said a respondent from India. But the “CD4 machine needs to be … in all primary health centers to increase access,” the respondent added.
A CD4 counter with a blood sample cartridge in use
“[Uganda] complies with treatment support guidelines offered by WHO. Without knowing the CD4 cell count, prescribing the right regimen and drug combinations becomes difficult for healthcare service providers,” said a survey participant from Uganda.
Health care workers considered CD4 testing crucial for the management of HIV but said it is insufficiently implemented. While most respondents — 91% — agreed that people who test positive for HIV should undergo such testing, only 55% said health care practitioners in their countries typically recommend it to people who are newly diagnosed with HIV.
Overall, they cited limited CD4 testing equipment, limited public access to CD4 testing, and a lack of domestic funding as the top barriers to implementation in their countries.
Other reasons that clinicians fail to recommend CD4 testing include a lack of well-maintained machines and an insufficient supply of reagents due to a lack of funding.
Regarding the use of CD4 testing in their focus countries, respondents said the top barriers were limited testing equipment, at 57%; limited public access to testing, at 48%; and a lack of domestic funding, at 45%.
“Clinical staging is typically used to diagnose AHD, which can still be improved. We don't have enough point-of-care CD4 machines, so laboratory results take a long time to come back,” said a respondent from Zambia.
Meanwhile, a health care worker from the Democratic Republic of Congo said:
The gold standards are clinical staging and CD4 testing. Unfortunately, the reagents are not always available.
The unavailability of reagents is likely due to lack of funding. The Clinton Health Access Initiative, in its 2019 “HIV Market Report,” suggested that "although there is sufficient aggregate CD4 testing capacity in many countries to meet all of the AHD screening need, access to onsite POC [point-of-care] CD4 testing varies by country and a lack of funding for reagents and programmatic support remain the key barriers to meeting this need."
Yet another factor is the current emphasis on scaling up viral load testing for treatment monitoring. According to a survey respondent from Kenya, “more support is required for CD4 testing as a lot of focus is currently on viral load testing.”
Donor funding has shifted away from CD4 testing and toward viral load testing, 49% of respondents agreed, while only 17% said it has not. In addition, 45% said there is not enough domestic funding for CD4 testing in their countries.
“CD4 testing is domestically funded, which is becoming less and less affordable,” noted a respondent from South Africa. A respondent from Nigeria said: “There is not enough funding for CD4 testing because it is donor-driven. The government needs to have a policy that would allocate the costs of CD4 testing into the budget for sustainability.”