Understanding Absolute CD4 Count and CD4 Percentage

Doctor swabbing a patient's arm with an alcohol wipe before drawing blood
Jim Gathany/Centers of Disease Control and Prevention (CDC)

Measuring CD4 T-cells are important in helping doctors determine the stage and likely outcome of HIV infection. While they are no longer used to determine when HIV therapy should be started—therapy should always be started at the time diagnosis—they can provide doctors a clear idea of how the person is and what can be done to improve his or her long-term health.

Understanding CD4 and CD8 T-Cells

To begin, lymphocytes are a type of white blood cell that helps the body fight infection. There are two main types of lymphocytes: B-lymphocytes and T-lymphocytes. Of these, there are two types of T-cells we monitor during the course of an HIV infection:

  • CD4 T-cells which are T-lymphocytes that have molecules called CD4 on their surface. They start the immune response by signaling other defensive immune cells to infectious pathogens such as bacteria and viruses.
  • CD8 T-cells which have molecules on their surface called CD8. These are the "killer" T-lymphocytes tasked with destroying infected cells and producing antiviral substances that fight off infectious organisms.

The Value of the Absolute CD4 Count

The absolute CD4 count is a measurement of how many functional CD4 T-cells are circulating in your blood. The lower the absolute CD4 count, the weaker the immune response.

The absolute CD4 count is measured by a simple blood test, the results of which are reported as the number of CD4 cells per cubic millimeter of blood. HIV-negative people typically have absolute CD4 counts between 600 and 1200 CD4 cells per cubic millimeter. By contrast, immune-suppressed individuals with HIV have counts that are typically less than 500, depending on the stage of infection, while people with advanced HIV can have 200 or less CD4 T-cells per cubic millimeter.

The absolute CD4 count is considered the best tool by which to predict the risk of HIV progression.

What the CD4 Percentage Tells Us

The CD4 percentage represents the percentage of total lymphocytes that are CD4 cells and is measured using the same blood test as that for the absolute CD4 count.

Typically, HIV-negative people will have a CD4 percentage of about 40 percent, while HIV-infected people's CD4 percentage can be as low as 25 percent or less. Clearly, the higher the percentage, the more robust the immune response.

If your CD4 count is lower than you expect, the CD4 percentage can put it into better perspective by telling this whether this is an actual change or just a fluctuation.

CD4/CD8 Ratio as a Snapshot of Immune Health

One way to gain better insights of a patient's immune function is to additionally examine the patient's CD4/CD8 percentage, which assesses the number of CD4 T-cells compared to the number of CD8 T-cells. With the test, we can see if the disease is progressing by tracking the depletion of "killer" T-cells in blood samples.

Typically, in advancing disease, as the immune system becomes exhausted, it is less able to produce T-cells to defend itself. The CD4/CD8 percentage helps us see this.

In recent years, greater emphasis has been placed on the CD4/CD8 dynamic in the aging HIV population. Recent clinical studies have suggested that patients on effective, long term ART with a low CD4/CD8 ratio have an increased risk of non-HIV-related morbidity and mortality.

Why These Tests Are Important

The absolute CD4 count and CD4 percentage give your doctor a snapshot of the health of your immune system, as well as the prognosis of your disease moving forward.

In its simplest form, we know that CD4 counts of less than 200 place a person with HIV at risk of opportunistic infections. The CD4 percentage, meanwhile, takes into consideration the total number of lymphocytes and is somewhat more predictive of a person's immediate and long-term health.

If, for example, the CD4 count is higher only because the total lymphocyte count is higher, we would still have a cause of concern about the patient's health. If, on the other hand, the CD4 is lower as a result of a lower lymphocyte count, we could interpret outcomes differently.

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Article Sources

  • Gompels, M.; Dunn, D.; Phillips, A.; et al. "Does Discordancy Between the CD4 Count and CD4 Percentage in HIV-Positive Individuals Influence Outcomes on Highly Active Antiretroviral Therapy?" J Infect Dis. 2012; 205(4):540-547.

  • Sauter, R.; Huang, R.; Ledergerber, B.; et al. "CD4/CD8 ratio and CD8 counts predict CD4 response in HIV-1-infected drug naive and in patients on cART." Medicine. 2016; 95(42):e5094.