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Page 4 of 4 Scientific Letter

The strength of this study is the large sample size from a Funding information
routine patient-level data set that includes clinical variables. This study is made possible by the generous support of the
However, there are a number of limitations. Firstly, a post- American people through the US President’s Emergency
baseline CD4 test was missing in more than half the cohort, Plan for AIDS Relief (PEPFAR) through the United States
which may have introduced bias into the estimation of INRs. Agency for International Development (USAID) under
This estimation may also have been somewhat inflated by the Cooperative Agreement number 72067418CA00023 for the
inclusion of CD4 tests performed up to 2 years after the VL Accelerating Program Achievements to Control the Epidemic
test. Secondly, we did not have access to all post-baseline (APACE) Activity in South Africa to the Anova Health
CD4 and VL tests; only the most recent result was available. Institute. The contents are the responsibility of Anova Health
We could, therefore, not assess change in CD4 count over Institute and do not necessarily reflect the views of USAID or
time following ART initiation, nor could we assess timing of the United States Government. The funders had no role in
viral suppression amongst patients with treatment failure study design, data collection and analysis, decision to publish
who were switched to a second- or third-line regimen, which or preparation of the manuscript.
may have impacted time to CD4 recovery. Thirdly, we only
had access to CD4 test results that had been captured into
TIER.Net. CD4 counts that were missing from TIER.Net Data availability statement
could, therefore, not be included in the analysis. It is unclear The data that support the findings of this study are available
whether missing CD4 data represent poor implementation of on request from the corresponding author K.R. The data are
CD4 testing in clinical practice or a data capturing problem, not publicly available because they contain patient-level HIV
and this warrants further investigation. Finally, although we information that could breach patient confidentiality.
believe the study sample to be generally representative of the
South African population as it includes both urban and rural
areas, as well as districts with high and low socio-economic Disclaimer
status, findings should be extrapolated to other areas with The views and opinions expressed in this article are those of
caution, particularly because this was not a random sample. the authors and do not necessarily reflect the official policy or
position of any affiliated agency of the authors.
In conclusion, it is essential that healthcare workers are
educated regarding the ongoing importance of correctly References
implementing CD4 testing guidelines in the universal test
and treat era to identify patients with low CD4 counts who 1. World Health Organization. Guidelines for managing advanced HIV disease and
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Authors’ contributions 7. Engsig FN, Gerstoft J, Kronborg G, et al. Long-term mortality in HIV patients virally
suppressed for more than three years with incomplete CD4 recovery: A cohort study.
K.R. conceived the study. R.R.L. cleaned the data and BMC Infect Dis. 2010;10:318. https://doi.org/10.1186/1471-2334-10-318
performed the analysis. N.D., L.G. and K.R. assisted with the 8. National Department of Health of South Africa. National consolidated guidelines
for the management of HIV in adults, adolescents, children and infants and
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J.A.M. and H.E.S. supervised the project and obtained the 9. Massyn N, Barron P, Day C, et al., editors. District health barometer 2018/19.
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funding. All authors critically reviewed and edited the 10. Woldesenbet SA, Kufa T, Lombard C, et al. The 2017 National antenatal
manuscript and gave their consent for publication. sentinel HIV survey key findings, South Africa. Pretoria: National Department
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